the history of the surgical service - San Francisco General Hospital

THE HISTORY OF THE SURGICAL SERVICE
AT SAN FRANCISCO GENERAL HOSPITAL
William Schecter, Robert Lim, George Sheldon,
Norman Christensen, William Blaisdell
i
DEDICATION
This book is dedicated to our patient and understanding wives
Gisela Schecter, Carolee Lim, Ruth Sheldon, Sally Christensen,
and Marilyn Blaisdell. Their help and support not only made our
careers possible but also ensured that they would be successful.
ii
PREFACE
I was delighted and honored to be asked to assist in the
publication of this landmark book on the History of Surgery in the
San Francisco General Hospital. The authors are to be
commended on their accurate, readable and historic portrayal of
the evolution of this center of excellence in trauma and general
surgical patient care. As I read through the manuscript, it brought
back warm and clear memories of days spent here both as a junior
medical student and later as a resident in the University of
California, San Francisco surgical program. It presents an
impressive timeline of surgeons who have taught here, a number of
whom have moved on and become outstanding leaders in the field
of surgery. After 40 years of practice as a surgeon, I look back on
my training here at this hospital as one of the most important
contributors to my overall surgical and medical education. This
hospital and its surgical staff imbued me with the essential
knowledge and technical skills necessary to be an accomplished
general surgeon and, most importantly, they taught me the value of
seeking advice from a more experienced specialist when the
occasion arose.
I feel certain that every surgeon, who during their training
has passed through the portals of San Francisco General Hospital,
will also find in this book a powerful reminder of how important it
has been in their life.
Robert Albo
Oakland, California
September 2007
iii
CONTENTS
Dedication
Page i
Preface
Page ii
Introduction
Page 1
Chapter I
The Brunn–Rixford–Eloesser Years:
1915-1945
Page 2
William Blaisdell
Chapter II
The Mathewson–Goldman Years:
1915-1966
Page 34
William Blaisdell
Chapter III
The Blaisdell Years:
1966-1978
Page 77
Robert Lim, George Sheldon
Chapter IV
The Trunkey Years:
1978-1986
Page 150
William Schecter
Chapter V
The Lewis Years:
1986-1993
Norman Christensen
Page 185
1
INTRODUCTION
The authors of this history of San Francisco City and County
Hospital—also known as San Francisco Hospital or San Francisco
General Hospital (SFGH) by its official names over the years—
have enjoyed putting this document together. It not only serves as
the surgical history of this hospital, still affectionately referred to
as “the County,” but it also represents the history of surgery itself
during the 20th Century. This was the period described as the Age
of the Surgeon, as it was during this period that our specialty
emerged in full flower.
Throughout almost its entire history, San Francisco General
Hospital has served as a training ground for medical students,
interns, and residents. In 1864, Hugh Toland built his first medical
school adjacent to the original County Hospital in North Beach,
and in 1865, Toland was granted permission to use the hospital for
clinical instruction. In 1872, Toland Medical School became the
medical school of the University of California (UC).
In 1872, a new County Hospital was built on the present
Potrero site. In 1879, UC negotiated an agreement with the San
Francisco County Supervisors that gave the University
responsibility for professional care and staff appointments and
allowed medical students’ access to patients. Shortly thereafter,
Cooper Medical College, which in 1908 became Stanford Medical
School, developed a similar arrangement.
At the same time, four internship appointments were
negotiated—two for UC and two for Stanford. The number of
internships was gradually expanded, but it was not until the new
brick and mortar hospital opened in 1915 that the first junior
residents, called house officers, were added. Formal postgraduate
surgical training emerged gradually during the 1920s.
Our description of the County Hospital Surgical Services
starts in 1915 with the dedication of the new hospital, called the
Renaissance Hospital because of its filigreed appearance.
Definitive organization of the Surgical Services, including the
specialties of surgery, dates from that time. Formal training
programs in surgery followed shortly thereafter during the 1920s.
The contribution of the hospital and its surgical staff,
including its flamboyant chiefs of service, to the care of patients
and to the development of surgery are the subject of this book.
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CHAPTER I
THE BRUNN–RIXFORD–ELOESSER YEARS: 1915–1945
In 1915, the new San Francisco General Hospital opened located
between the Mission District and Potrero Hill. It was appropriately referred to as
the Renaissance Hospital, as it was solidly built of brick in pavilion style with
all the fancy accoutrements of the bricklayer’s art.
The Administration Building, centered between four towers that housed
patients’ wards, was three stories high. The first floor contained the
administrative offices and the telephone exchange and switchboard. In addition
there was a large room for the visiting staff, which was also available as a
committee meeting room. The upper two floors were devoted to the use of the
residents and interns. They contained a library and a billiard room in addition to
the physicians’ quarters and communal bathrooms.
The Receiving Building on the north end of the complex facing 22nd
Street was four stories high. The first floor contained the Emergency Service—
Mission Emergency—which was moved to this site from a separate building a
block away and which, although administratively separate, was incorporated
physically into the new hospital. This emergency room (ER) included procedure
rooms, separate observation wards for men and women, and eight isolation
rooms. The first floor also included an outpatient clinic, Social Service, and a
dental clinic.
The second floor contained the surgical pavilion. Besides standard
operating rooms, the surgical pavilion included two large amphitheaters (east
and west), each with seating accommodations for 50 students. On this floor were
the xray department, the eye and ear, nose, and throat and the urological
examination rooms, as well as a recovery room.
The third floor was occupied by the amphitheater, which had seating
accommodations for 200 people, and small laboratories on each side—one for
3
each of the two medical schools. The fourth floor contained the extension of the
amphitheater as well as several offices.
The hydrotherapy department was located in the basement. At that
time it was described as “second to none in San Francisco.” It was equipped
with dressing and lounging rooms and douche, steam, and irrigation rooms.
There was also a pool and a “mechanical apparatus” department.
The four main ward
buildings were initially four
stories high. Each building had
four 29-bed wards, a roof
garden with a penthouse, and a
basement. There were 25 beds
in the open ward, two isolation
rooms with two beds each, a
solarium, a treatment room,
and a kitchen. A special
feature was the sanitary tower on the middle north side of each ward, which
contained the toilets, baths, wash basins, a utility station, and a laundry chute.
Ultimately the roof garden was converted into an additional, fifth, floor.
A separate pathology building was constructed on 22nd Street, just east
of the Receiving Building. The first floor contained the autopsy amphitheater,
ice boxes for the morgue, and an animal research lab. The second floor
contained the pathology laboratories and offices. The third floor contained
Health Department laboratories.
An isolation building of three stories with 120 isolation cubicles
occupied the central east area. Several years after completion of the main
hospital, a 500-bed tuberculosis building was completed on the southeast corner
of the property, fronting on 23rd Street. The first year the hospital was open, the
annual expenditure was $333,000. The State of California subsidized 85
tuberculosis patients at $3.00 per week.
HISTORY
The first true San Francisco City and County Hospital was established
in 1857 in a building originally constructed as a school on the north side of
Telegraph Hill, in the North Beach area. Dr. Hugh H. Toland built his medical
school next door in 1864 and obtained permission from the City and County to
educate his medical students there in 1865.
4
Left Toland Medical School, Right County Hospital
Hugh Toland arrived in San Francisco in 1852. He had been a
successful physician in South Carolina, but left for California to search for gold.
He found gold mining too tough and retired into the easier business of doctoring.
Within a few years, he was making the unbelievable sum of $40,000 a year, the
major basis of which was his large mail-order business and pharmacy. Using
Wells Fargo as an intermediary, he diagnosed and prescribed by letter for
countless people isolated in the remotest areas of California and Nevada. His
chief remedies were kept behind the counter of his drugstore in two barrels,
which were labeled anti-scrof (tuberculosis) and anti-syph (syphilis). Upon these
two barrels were laid the financial foundations of the future medical departments
of the University of California
When the hospital exceeded its capacity, it was time to look for another
site. Toland fought to have the City build on the original site or in the immediate
vicinity. Unfortunately, Dr. R. Beverly Cole—Toland’s antagonist in a notorious
dispute—was successful in ensuring that the hospital was located as far away as
possible, out in the sand dunes south of the City on what was to become Potrero
Avenue. The antagonism between the two men was the result of a difference of
opinion regarding management of the wound of a crusading newspaper
publisher, James King. In 1856, King was shot in the left upper chest by a
corrupt politician, James Casey. A group of prominent physicians led by Toland
vied to take medical charge. The wound was explored with the bare fingers of
the group of consultants and, in a cacophony of divided opinion, Toland inserted
a sponge into the bullet tract to tamponade the bleeding. Almost immediately,
cries of malpractice were initiated by Beverly Cole, who had been a close friend
5
of the newspaperman. Cole, who was in his twenties at the time, believed he had
been humiliated by the 50-year-old Toland during the discussion at King’s
bedside. The wound putrefied and King died. At his jury trial for malpractice,
Toland forcefully argued that the death resulted from subclavian vein phlebitis
and shock in a man with obviously poor resistance. The jury returned a verdict
of no malpractice. In a strange twist of fate, Cole later became Dean and
President of Toland Medical School and helped to lead its transfer to the
University of California (UC) in 1875.
The initial hospital, constructed on the Potrero site in 1872, was a
clapboard hospital, cheaply built and designed to be replaced within a few
decades. It lasted until a
second plague epidemic in
1908, when the rats in the
hospital became infected
with the disease and the
hospital was abruptly burnt
down. It was replaced by the
magnificent new structure in
1915.
The
clapboard
hospital had been shared by
six medical schools, but
only Stanford and the UC
Medical Schools survived
the 1906 earthquake, the 1908 fire, and the Flexner commission, which was
setting standards for medical schools. From that point until 1960, hospital
services were shared between the two medical schools, UC and Stanford.
CHIEFS OF SERVICE
There were four chiefs of the Surgical Services from 1915 until 1945.
For the UC Service there was Harold Brunn, who was appointed chief of the UC
Service in 1910, where he served until he retired in 1942. Horace McCorkle
briefly succeeded him as chief. McCorkle served from 1942-1945, when he in
turn was succeeded as chief by Leon Goldman. For the Stanford Service,
Emmet
Rixford
was
appointed chief in 1905. He
retired in 1930 and was
succeeded by Leo Eloesser,
who remained chief of the
Stanford Service until 1946,
when he was succeeded by
Carl Mathewson.
All these men were
paid, at best, a small stipend
by the hospital and by the
UC Medical School 1900
Medical School for their
supervision of patient care and for teaching medical students. All supported
themselves by their private practices. Brunn worked chiefly at Mt. Zion
Hospital, Rixford at Stanford, Eloesser at St. Luke’s and French Hospitals, and
McCorkle at Franklin Hospital, which was later called Ralph K. Davies Medical
Center.
6
Harold Brunn
Born in 1874, Harold Brunn was
raised in San Bernardino, California. He
obtained his M.D. degree from the
University of Pennsylvania in 1895. He
then elected to study in Germany. To
young Americans, Germany was a
fabulous land of medical progress and
accomplishments. His year of European
travel took him to Breslau, where
Mikulicz and Wölfler, the latter a pupil of
the great Billroth, were pioneering in
gastric surgery. He then went to Leipzig
where Volkmann had just performed the
first excision for cancer of the rectum. He
also had the chance to visit
Trendelenburg’s clinic and observe the
rapidly expanding discipline of pathology.
At the completion of his year in Germany, he returned to California and
elected to set up surgical practice in San Francisco as the junior associate of
Douglas McMonigle. McMonigle had established himself professionally in
gynecological surgery. He had established a Women’s Hospital and helped to
develop surgery at Children’s Hospital
Private practice did not entirely satisfy Brunn. Before the end of 1898,
he had volunteered to teach pathology at Dr. Toland’s Medical School, now the
University of California.
Brunn was a robust, hearty, stout, brilliant fellow with a fabulous
memory who dominated any meeting he attended. At social affairs he had an
inexhaustible fund of dirty stories and a hearty belly laugh. Dr. Leo Eloesser
described Dr. Brunn as “a kindly, jolly man, better as a surgeon, organizer, and
administrator than as a teacher.”
One of Brunn’s early acquaintances in San Francisco was Thomas
Huntington, a man of culture, vigorous will, and striking personality. Huntington
performed an operation using the Listerian method for the first time in
California. Initially, he struggled against his frontier colleagues, who offered
vigorous opposition to this “new-fangled method.” Late in the 19th century,
after winning his fight and gaining recognition and acceptance, he was made
professor of Surgery at the University of California. Huntington chose Brunn as
his assistant, and this appointment launched the young surgeon on a
distinguished career as a university clinician, teacher, and researcher.
There was a change in the organization of the University of California
Department of Surgery following the earthquake in 1906. Wallace Terry became
chief of the Department and professor of Surgery, and he separated the service
of the University Hospital from that of San Francisco Hospital—which by this
time had become geographically separated. The University then appointed
Harold Brunn associate clinical professor and gave him full authority for
administration, patient care, and surgical teaching on the UC Surgical Service,
7
San Francisco (County) Hospital. The Civic authorities at that time could not be
induced to provide laboratory services, so—at his own expense and some
meager aid from the University—Brunn established a bacteriology and
pathology laboratory.
Then, in 1908, the plague presented a second time. Its presence within
the hospital’s rat population was verified by Brunn’s laboratory. There was no
choice but to close and burn the hospital.
While the new San Francisco Hospital was being designed and built,
the hospital was temporarily relocated to the old Ingleside Racetrack. There,
under adverse circumstances, the Surgical Service carried out its mission in the
horse stables and under the grandstand until the new hospital could be
completed.
The magnificent new hospital was opened in 1915 and for the first time
provided adequate physical facilities for surgery to develop. Brunn was able to
expand his interest in thoracic surgery, which he had acquired in Germany. By
this time, the bronchoscope had become available and had proved to be a
valuable instrument, facilitating the diagnosis of bronchiectasis, early cancers,
and bronchial tumors. Tuberculosis care had been provided a separate building
in the new hospital complex, and this disease provided major challenges for the
thoracic surgeon.
Recognizing his efforts in the field and because of his services to their
family, the Roos family endowed the J.J. and Nettie Mack Foundation at the
University of California Medical School. They directed that it should be devoted
to the study of cancer and chest surgery under the guidance of Dr. Brunn.
Of the 34 major contributions to the surgical literature in Brunn’s
bibliography, 20 are concerned with intrathoracic pathology or thoracic
operative procedures. The first appeared in 1926. According to Eloesser, Brunn
was the first surgeon in the United States (U.S.) to carry out definitive
lobectomy. Before the introduction of Brunn’s operation, lobes were resected in
stages, being tied off with mass ligatures, separated from the rest of the chest by
gauze packs, and allowed to slough. Brunn was the first to resect the lobe, tie the
vessels, sew up the bronchus, and close the chest. He used this procedure for
bronchiectasis and cancer. He carried out valuable studies on benign bronchial
tumors and recognized bronchial adenoma as a clinical entity.
At the time of his retirement, Brunn’s many contributions to thoracic
surgery were acknowledged. The dedication in the book presented to him on his
retirement read, “Today a poor young girl with bronchiectasis, becoming a
reeking stench, an offense to her fellows, driven to despair, her life an abiding
horror, can find relief and redemption. A man with an abscess of the lung or
another with a gangrenous pulmonary patch, can be restored from the
distressful, disabling disease, for it is possible for the thoracic surgeon to remove
a lobe, half a lung, or, if need be, a whole lung. A pneumothorax done,
intrapleural adhesions cut, a lung collapsed and more often than not the patients’
return to vigor, to earning power; their rightful place in society is assured. This
was due to the Thoracic Clinic of the University of California under Harold
Brunn.”
In regard to teaching, Brunn devoted much time, ingenuity, and effort
in setting up clinical demonstrations and schedules that increased the
effectiveness of surgical teaching. In combination with Leroy Briggs, the Chief
8
of Medicine, he established San Francisco Hospital as an outstanding
educational experience for UC medical students.
He had a tremendous sense of humor and enjoyed telling bawdy jokes.
He liked to host his junior colleagues and housestaff at the St. Francis Yacht
Club, where he entertained with personal anecdotes, clinical asides, and the
latest jokes and stories. At the time he retired in 1942, at age 65, his staff
presented him with a book dedicated to him. It contained, in addition to his
biography and personal tributes, clinical papers they had written especially for
this publication. They acknowledged “his personal enthusiasm, his amazing
energy, his lust for life, and his willingness to serve his fellow men as physician,
teacher, and friend”
Emmet Rixford
Emmet Rixford was born in 1865
in Bedford, a small town in Canada near
the Vermont border. His father was a
Vermonter, his mother a Canadian. When
he was two years old, the family set out
for California, taking a side wheeler ship
to Nicaragua. They crossed overland to
the Pacific, and from there traveled to
California by ship. His father secured a
position with the San Francisco Bulletin
and later worked for the State Department
in horticulture, where he was directly
responsible for the introduction of the
Smyrna fig and several hardy varieties of
citrus fruit to California.
Rixford attended San Francisco
public schools and entered the University
of California as a student of engineering.
He was graduated in 1887. He said that his engineering studies served him in
good stead—they helped him understand the mechanism of fractures, a subject
in which he had a major clinical interest.
After graduating in engineering, he
received his M.D. degree from Cooper
Medical College in 1891—Cooper
became Stanford Medical School in
1908. In 1892, soon after obtaining his
medical degree, Rixford left for the East
Coast, where he spent a year at the New
York Hospital for Ruptured and Crippled
under the elder Dr. Coley. During the
summer of 1892 he worked at Johns
Hopkins
in
Welch’s
pathology
laboratory.
In 1893, Rixford returned to
San Francisco and opened a surgical
practice. He was appointed adjunct
professor of Surgery at Cooper Medical
College in 1893 and professor in 1898.
Stanford Medical School
9
Initially, he served as an assistant to Levi Cooper Lane, the founder of, and chief
surgeon for, Cooper Medical College. Lane, although a brilliant technical
surgeon, never accepted the principle of asepsis. This was something Rixford
adopted on his own, perhaps as the result of the influence of William McEwen
of Glasgow, who came to San Francisco in 1896 to give the first of the annual
Lane lectures.
When Lane retired in 1905, his two protégés, Emmet Rixford and
Stanley Stillman, were appointed joint chiefs of Surgery. Rixford elected to take
the City/County Hospital as his main administrative responsibility, while
Stillman took responsibility for Lane Hospital, which was attached to Cooper
Medical College. Teaching responsibilities were also divided between them.
When Cooper Medical College became part of Stanford University in 1908,
Rixford continued in the same role as a Stanford professor of Surgery.
Rixford’s Thursday
morning
rounds,
or
“colloquia,” were attended
by numerous surgeons in
addition to his students,
whom he both instructed and
entertained at the bedside. A
major operation would be
scheduled for him in the
surgery amphitheater. He
would gown and put on a
special mask with an apronlike attachment, which was
Typical Open Ward in this Era
then tucked in at the waist of
his ample belly to cover his beard. In deference to asepsis, he would rinse his
hands and arms in a solution of bichloride of mercury and then don his sterile
gloves.
He was resourceful and quick in operating and decisive in judgment.
He was abundantly laden with information, and he had an encyclopedic mind.
He was a brilliant teacher at the operating table, where he would expose and
discourse on the anatomy. He always had a large blackboard present, which he
would use to further illustrate the procedure he was doing. The chalk was
secured in a sterile towel, but sometimes, in his artistic enthusiasm, he would
inadvertently contaminate himself. While his lectures were often described as
brilliant, they were usually over the heads of his students and were best
appreciated by his surgical house officers or fellow surgeons.
His activity as a surgeon bridged the period between antiseptic and
aseptic surgery, between routine drainage and non-drainage of wounds. His
facile mind quickly accepted and promoted developments in surgery. Early on,
he insisted on a bacteriologic and pathologic study of his operative specimens,
and he was himself an excellent surgical pathologist. He was one of the first
surgeons on the West Coast to use xray, and with it he was able to locate a
foreign body in the brain and successfully remove it.
His research into fractures and dislocations led to his writing several
papers on the subject, including papers on the production and treatment of
greenstick, buckling, torsion, and flexion fractures. His first paper, in 1894, dealt
with the symptoms and diagnosis of tuberculosis of the joints. Other papers
10
covered the gamut of general surgery and included the treatment of hernia,
goiter, pancreatitis, renal stone, gallstones, and cancer of many sites. He sent
some interesting pathological material to Drs. Welch and Gilchrist at Johns
Hopkins Hospital, which led to the recognition of a new disease,
coccidiomycosis (Rixford and Gilchrist Johns Hopkins Hospital Reports 1896).
One of his great accomplishments was the founding and development
of the Lane Medical Library of Stanford Medical School. He personally solicited
books and journals, including duplicates he found in the Surgeon General’s
Library and 24,000 volumes he obtained when the New York Academy and
New York Hospital consolidated their libraries.
Rixford was president of the American Surgical Association, founder
and president of the Pacific Coast Surgical Association, and twice president of
the San Francisco County Medical Society. In 1928, at the request of Harvey
Cushing, he served as surgeon and chief pro tem of the Peter Bent Brigham
Hospital in Boston.
He had many interests and hobbies outside of medicine. He was a
naturalist and explored the Sierra Nevada Mountains. He climbed their peaks,
and Mount Rixford in the Kearsarge range is named after him. His reputation as
an authority on rose culture was nationwide. He was an authority on land snails
and possessed one of the country’s most complete collections. He was skipper of
the sloop Annie, and Commodore of the fleet in San Francisco Bay.
Rixford died in Boston in 1938 following an operation for cancer of the
bladder.
Leo Eloesser
This remarkable man with
global interests was born in San
Francisco in 1881 of German immigrant
parents. The family was wealthy from
manufacturing “Can’t Bust ‘Em”
Overalls. His father was a pianist, and
Eloesser and his three siblings were
encouraged to study music. Upon
graduation from Urban School in San
Francisco, Eloesser was too young to be
admitted to the University of California,
so he studied music, which he wanted to
pursue as a career. But a family friend,
ophthalmologist
Adolph
Barkan,
convinced him that he should study
medicine. When Eloesser was subsequently admitted to UC, he failed most of
his courses, and only with the intervention of his father was he given a chance to
continue. At that point, he became a serious student and was graduated in 1900.
Dr. Barkan insisted that Eloesser should study medicine in Germany at
the University of Heidelberg where Barkan knew the Surgery professor,
Vincenz Czerny. Eloesser was enthralled with the German system of teaching
because there was academic freedom, and no one cared whether the students
attended classes or not. It was only necessary that the student pass a series of
examinations. This allowed him freedom to pursue his interest in music in
parallel.
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On completing his studies and being awarded his degree in 1907, he
became a voluntary assistant to Czerny. During this period he spent six months
in the pathology laboratory, gave anesthetics, and wrote a treatise on pancreatic
diseases. He spent several years in Germany and, during this period, visited the
Clinics of Mikulicz and Sauerbruch. Following this experience, he spent
six months in England and worked in Sir Almoth Wright’s laboratory in St.
Mary’s Hospital.
In 1909, he returned to San Francisco and, because it was six months
before he could qualify for licensure, he volunteered as an intern on the UC
Service at San Francisco City and County Hospital. At that time, the hospital
was temporarily located at the Ingleside Racetrack while the new County
Hospital was being designed and built.
After a six-month internship, he rented an office and began private
practice. He disclaimed any immediate success saying, “I spent more and more
time at the hospital and less and less at the blank, patient-less office. It was ten
years before I collected sufficient fees to pay the office rent.” His colleagues
said that the reason he earned so little was a consequence of charging so few of
the patients he treated, and charging so little to those he did. Finally, in January
1914, he told his father that he no longer needed monthly checks. “I have $500
in the bank and shall get on alone”.
He stayed on the UC surgical staff, whose chief was Wallace Terry,
while he set up his private practice. In 1912, Emmet Rixford, chief of the
Stanford service, offered him a position and Terry advised him to take it because
Terry considered the status of the UC Medical School tenuous. The UC Regents
felt that it represented a costly drain on the rest of the University and were
considering closing it.
During his initial period at Stanford, Eloesser did a great deal of
experimental work on animals. He was also a courageous surgeon, for—having
been exposed to the German system—he was willing to undertake procedures
that other surgeons would not. Some of these operations were bold and risky,
but they were often successful. His operations were noted for his use of the
smelly, smoky, Percy cautery.
Eloesser was of slight build and barely over five feet tall. He had an
intense look, a penetrating gaze that could skewer any mortal, and an extremely
caustic tongue. He drove himself hard and expected others to follow his
example. Woe be it to the verbose student as he made rounds, and woe to the
resident who tried to bluff his way through a history or diagnosis. A retort of
“Bullshit” could be his lot. Because of his diminutive size, Eloesser usually
operated standing on a stool. Having been grounded in the fundamental branches
of medicine and Germanic
teaching, he knew pathology well
and was able to examine his own
microscopic sections, which he
apparently did with great accuracy.
Eloesser was an adequate,
but not a brilliant, technician. His
fame came primarily from his
diagnostic acumen. His colleague
in medicine, Harold Hill, found
that he was the most reliable and
Eloesser at Bedside with Dr. Hill
12
accurate diagnostic consultant he could find in the city. His capability as a
diagnostician was attributed to his attention to detail, his broad acquaintance
with the world literature, his clear logic, and his intelligent deduction. His
colleagues believed that the splendid outcome of his treatment was based not
only upon excellent preoperative evaluation and preparation and proper
operative management, but also upon the best and most conscientious
postoperative care possible. If a postmortem examination could be obtained, he
always attended the autopsy or did the autopsy himself.
As a teacher, Eloesser was described as unexcelled. He emphasized
analysis over rote memorization. He emphasized using the mind critically and
analytically to discard outworn, untrustworthy, and unsubstantiated opinions;
and he held that the spoken and written word was not necessarily true because it
was “authoritative.” He said, “I think that we all agree, in theory if not in
practice, that trying to impart facts to students is futile, especially trying to
impart them by word of mouth. Anyone in search of facts can find facts out by
himself if he wants to.”
Eloesser used the Socratic method to prod a student to make logical
deductions. “Technique? Ha! That is an easy thing to teach, a thing that should
be taught, not to undergraduates of course, but to aspiring surgeons. Technique
can be taught and it can be learned; learned by all the four avenues by which we
learn any manual activity—by listening, watching, practicing, and doing. Some
men’s hands will surpass their heads; for others, intellect will prevail over some
clumsiness. It is our business as guides and teachers to recognize our pupils’
fortes; to do what we can to curb the dexterous avidity of the technically agile,
and to stimulate the clumsy to practice their five finger exercises.”
Eloesser was insistent that his students and trainees understand clearly
that to know a patient’s symptoms, the abnormal findings on physical
examination, the correct diagnosis, and even the treatment, was not enough.
“Over and beyond this, they must try to unravel the puzzle—what is wrong
anatomically; what was functioning improperly? What in essence is at the basis
of the disordered state? If death should come, why?”
He was a brilliant scientific writer and began publishing while he was
still in training. His observations about the management of German war
casualties were published in the Journal of the American Medical Association
(JAMA). He published a total of 92 articles—about half of them on chest
surgery. He also wrote papers on amputations, bone grafts, aneurysms, peptic
ulcer surgery, and anesthesia.
His patients appreciated his care and loved him. His thorough
evaluations assured them that no detail would be left to chance. He established
compassionate, understanding, personal relationships with them. His patients
could rest assured that if they were worrisomely ill or might profit from a visit,
he could be counted on to be there at any hour of the day or night.
An example of his care is a convict who was transferred to the County
for treatment. “It was a long, hard, smoky operation which ended about 1 PM.”
Eloesser then demanded that special nurses be obtained for the patient around
the clock for the first day or so. He was told that this was a Saturday and that
Social Service had closed at noon. There is no way to get approval for special
nurses. “Get them, I’ll pay for them myself,” he thundered.
As vouched for by Carl Mathewson, his junior associate at the County,
“Leo was a workhorse. He had no concept of time, day or night.” At the time of
13
his peak involvement at the County, he made staff and then student rounds from
8 to 12 on Wednesdays. Wednesday afternoons he spent in the pathology
laboratory. He operated at the County Hospital three days a week and very often
returned late at night to see how his patients were doing. By the 1930s, he also
had a busy private practice. He operated on private patients at French, St.
Luke’s, Stanford, and St. Joseph’s Hospitals and at the Dante Sanatorium. He
saw patients in his office until midnight, never turning anyone away who wanted
to see him. He worked Monday through Saturday.
He never married, but he was never without women friends. In the
1930s he drove a large open convertible and was always accompanied by his
dog, a German dachshund. His primary luxuries and relaxation were his boat
and his viola. He owned a 28-foot ketch, the Flirt, and sailed regularly with a
companion, often female.
He owned a flat on Leavenworth Street. Every Wednesday evening, a
small group from the San Francisco Symphony would join him in his flat to play
chamber music together. From time to time, this group was joined by
distinguished visitors such as Pierre Monteux, Fritz Kreisler, and Yehudi
Menuhin.
He had a gift for languages, mastering Greek, Russian, French, Polish,
Hungarian, Spanish, Italian, and Chinese. He once spent seven months teaching
at the University of Tokyo Medical School in Japanese, having picked up the
language from a dictionary and conversations with passengers on the ship going
over.
With the outbreak of World War I, he contacted his old chief, Professor
Czerny, in Germany, and was put in charge of a surgical division of a large
German hospital. There he published papers on the use of blood transfusion in
war surgery and on the management of gas infections. When the United States’
entrance into the War was imminent, he returned to America. He tried to enter
the U.S. Army, expecting his experience with casualty management would be
welcomed. but his German connections resulted in denial. However, he was
asked to supervise a large orthopedic and rehabilitation ward at Letterman Army
General Hospital in San Francisco. His ward was filled with amputees, and
when the Army dragged its feet about setting up a prosthesis center, Eloesser
went to Mare Island, borrowed machinery from the Navy, and set up an artificial
limb factory. This factory then produced the highly successful “Letterman leg.”
He also pioneered in the early fitting of these prostheses.
Even while working at Letterman, Eloesser went to San Francisco
County at night, where he saw many patients with empyema and other chest
diseases, which were now attracting his interest. At the end of the War, he
returned to his position as assistant chief of Stanford’s County Surgical Service
under Rixford and reopened his private office. The influenza epidemic of 1919
resulted in a flood of patients with lung abscess, bronchiectasis, and empyema,
which further stimulated his interest in thoracic surgery. In 1926, he brought in,
as his associate in private practice, his former house officer in surgery, William
Lister “Lefty” Rogers.
Eloesser's clinical interests were general. He always had a major
interest in fractures, which were then the province of the general surgeon.
However, as his private thoracic practice grew in volume, so did his research
interests in thoracic surgery. He became interested in tuberculosis and its
treatment. He devised the flap that bears his name, which he used for chronic
14
drainage of empyema. He was very proficient in bronchoscopy, a technique he
had learned in Germany, and he became interested in bronchial pathology and
bronchial stenosis in particular.
In 1934, he visited Russia and installed a ward for thoracic surgery in
the First University Surgery Clinic in Moscow. In 1937, after serving as
President of the American Association for Thoracic Surgery, he went to Spain
and served the Loyalist side in the Spanish Civil War for eight months. He took
with him his viola, an ambulance, and a staff of physicians and nurses he had
recruited. He set up a military hospital and developed a blood bank service.
While in Spain, he published a paper on the management of compound fractures.
He regularly sent home requests for his El Toro® Mexican cigarettes,
Ghirardelli® chocolates, and Hills Bros.® Coffee, to all of which he was
addicted.
He had many friends among artists and musicians; these included the
noted sculptor Ralph Stackpole and the Mexican muralist, Diego Rivera.
Rivera’s wife, Frida Kahlo, painted the picture of him that today hangs in the
lobby at San Francisco General Hospital.
Eloesser returned from Spain in 1938 and resumed his duties at the City
and County Hospital and his private practice. In 1945, he joined the United
Nations Relief Organization, gave up his work in San Francisco, and went to
China. As no one thought to acknowledge his retirement in the postwar ferment,
he gave a retirement party for himself. His friend sculptor Ralph Stackpole had
earlier immortalized Eloesser, peering through a microscope at the base of
Stackpole’s giant statue for the American Stock Exchange, Man and His
Inventions. Stackpole sculpted another statue, this time portraying Eloesser
sigmoidoscoping a horse, which was the centerpiece of the dinner. This
remained for many years in the hospital’s pathology laboratory before it
disappeared. “It was a jolly goodbye party.”
Once in China, Eloesser became disgusted with the corrupt regime of
Chiang Kai-shek and quietly made his way to Mao’s remote communist
stronghold. There, it was obvious to him that Western He worked with the
Communists for four years, living like a peasant and teaching hygiene,
sanitation, and midwifery to the “barefoot doctors.” He served at Bethune
Medical School and added Chinese to his repertoire of languages. He published,
in Chinese, a manual for rural midwives titled Pregnancy, Childbirth and the
Newborn. It was subsequently revised and published in Spanish, English, and
Portuguese. The latest edition appeared in 1976.
Eloesser returned from China in 1950 and continued to work with
UNICEF. He became interested in health care in third world countries. In San
Francisco, at age 70, he met his companion for the rest of his life, Joyce
Campbell. In the McCarthy anti-Communist era, he felt persecuted and
unappreciated; and in 1953, he retired to the isolated small town of Tacambaro,
Mexico. There he set up a small clinic to treat the disadvantaged in the area. His
fees, which were modest, were given to the town clerk at the end of the year and
were used to give Christmas presents to the prisoners in the County jail.
Three months before his death, Eloesser gained Mexican citizenship
and was awarded the Presidential Medal for his work with the poor of that
country. He saw patients until he died of a massive coronary occlusion on
October 4, 1976 at 95 years of age.
15
Horace McCorkle
Horace McCorkle, the oldest of three boys, was born in 1905 and raised
in Comfort, Texas. The family later moved to San Bernardino, where he
attended high school. He took his undergraduate work and his medical school
training at UC Berkeley, obtaining his M.D. in 1934. He interned in surgery at
UC from 1933-1934, and then entered his residency, completing it in 1939.
When McCorkle was chief resident, he met and was enamored with an
emergency room nurse, Marion Fisher. They married and had five children—
four boys and one girl.
McCorkle—“Mac” to his residents—stayed on the UC staff following
completion of his residency in 1939. When Brunn retired in 1942, World War II
was on, and Mac took over temporarily as chief of service at the County. During
the War years he was assisted by two of the recent graduates of the program,
Henry Silvani and Harry Peters.
McCorkle was a very private person—acerbic, quite stern and
somewhat autocratic, honorable, hard working and very precise. He was friendly
but not effusive, and one needed to know him well before there was much social
exchange.
He was deliberate and somewhat slow in surgery, although fast as
William Brock said, “When McCorkle operated, you couldn’t see any blood.
There was little conversation, everything was neat, and his technique was
superb. His radical mastectomies and thyroidectomies were right out of the
anatomy book. I think Mac was my best teacher of surgical technique. Because
his technique was so gentle, local anesthesia could be used. He was a proponent
of doing major upper abdominal cases under field block and local splanchnic
nerve block. These include biliary operations, gastrectomies and others.”
Initially, McCorkle had a difficult time developing much of a private
practice because of the poor economic times—and possibly part of the reason
was also related to his reserved personality. When Howard C. Naffziger, the
former Chair of Surgery, developed lymphoma, he selected Mac as his
physician. Mac continued to care for Naffziger until he died.
TRAINING PROGRAMS
Postgraduate training was not a requirement for practice during this
period, and most medical school graduates went straight into practice as
“licensed physicians and surgeons.” Stanford Medical School was unique in
requiring an internship—up until the 1960s, Stanford’s M.D. was deferred until
the completion of internship. UC did not require such training, but most of the
graduates enrolled in an internship. The most popular were the rotating
internships of the type provided by San Francisco County Hospital. As opposed
to the rotating internships at the County, the two Universities provided straight
internships for those wishing further experience in surgery, medicine, obstetrics
and gynecology (ob-gyn), pediatrics, or psychiatry.
By 1915, in addition to the rotating internships, house officer
positions—not yet called residencies—had been added, four for each University,
one each in medicine, surgery, ob-gyn and pediatrics-infectious disease.
There was one resident physician position. That physician served as the
administrator for the interns and house officers. During this era, all the residents
were men. The resident was selected from one of the two surgical house
16
officers. During odd years, he was a UC man, and during even years, a Stanford
man. There was one notorious temporary exception when Eloesser intervened
with the director of Public Health and Carl Mathewson, a Stanford house officer,
appointed in a UC year. The resulting brouhaha escalated as far as the
governor’s office, so that, after a few weeks, Mathewson was forced to give up
his post and go to Germany for further training.
Mathewson had learned of his out-of-turn appointment when he read
about it in the morning newspaper. That same morning he received a call from
the switchboard to let him know that there were three people waiting to see him
in the hospital lobby.
“The first one was the pharmacist from the drug store across the street,
who offered me $250 cash for my prescription book. This was during
prohibition when every doctor was issued a prescription book in which he could
order alcoholic beverages for his patients. Pharmacists naturally were interested
because they could sell liquor over the counter, provided that they had a
prescription to cover it.
“The second individual was a man who was apparently a pimp. He was
interested in the prostitutes who were confined to Ward M at the County
Hospital, under arrest until their vaginal smears and blood studies were negative
for disease. The pimp offered me $50 for each girl I would certify as negative.
“The third person was from an undertaking parlor in the Mission
District. He offered me $50 for every death that I would refer to his Mortuary.
“These individuals were astounded when I adamantly denied their
wishes and told them to get out of my sight and out of the Hospital. They argued
that I was going against established custom.”
In, 1926 UC had house officers in medicine, tuberculosis-medicine,
surgery, and ob-gyn, and 15 interns. Stanford had house officers in medicine,
surgery, orthopedics, ob-gyn, and pediatrics-infectious disease, and 16 rotating
interns. By 1930, UC had seven house officers and 18 interns, while Stanford
had one senior house officer, five junior house officers, and 19 interns.
In 1933, both UC and Stanford were given a chief surgery resident
position, ending the potential conflict for the one yearly position. That same
year, both Universities formalized their surgical training and developed a
progressive residency system leading to a chief residency after three to four
postgraduate years.
At UC, a surgical residency training program similar to that started by
Halsted at Johns Hopkins had been introduced. Howard Naffziger, professor and
appointed chair of Surgery at UC in 1929, had recruited H. Glenn Bell to run the
General Surgery program. Bell had trained at the University of Cincinnati,
where one of Halsted’s trainees, Mont Reid, had introduced a Johns Hopkinstype program. Bell’s new residency combined the University Hospital, San
Francisco County Hospital, and Franklin Hospital. Franklin Hospital, now called
Ralph K. Davies Medical Center, was the Hospital then used by the UC faculty
for their private patients. The UC positions at the County now included a chief
resident in surgery, an associate chief resident, and two surgical house officers.
The 20 rotating County interns were shared by all services.
As it was initially set up, the UC program admitted two junior residents
each year. During the second year, one of the two was sent to Cincinnati for a
year and the other to County as senior house officer. The latter became chief
resident at the County. The one in Cincinnati came back to be chief resident at
17
UC. The County chief resident was paid $39 a month and was in charge of all
the residents, not just those in surgery. It was not until after World War II that
chief resident positions were granted for specialty services other than surgery.
Emile Holman, William Halsted’s last residency trainee, had been
appointed chair of Surgery at Stanford in 1926, relieving Stanley Stillman, who
had retired. He had recruited an associate from Johns Hopkins who was to
succeed Rixford when the latter retired in 1930. However, Eloesser used his
political influence to bar the door to County Hospital and to get himself
appointed Chief. An estrangement ensued between Eloesser and Holman, and
each started and maintained a separate independent residency. Eloesser
instituted his independent program in 1933 in parallel with that of UC. His
positions reflected those of UC, so that his had a three-year training program in
surgery after one year of internship; internships remained independent of
residencies until the late 1960s.
During this period, interns were given room and board, were provided
with uniforms and laundry service, and were expected to live in the hospital.
Married applicants for internship were not accepted for training. Few, if any,
interns could afford a car. When they wanted to go someplace, they flagged an
ambulance.
Internship hours were long and the work was hard. Although
theoretically, always on call, interns would sign out to one another for a few
hours during the week if they thought they could get away with it. It was easier
to leave the hospital on weekends, when the administrators were absent.
However, a major scandal developed in 1924, when the hospital was hit with a
flood of emergencies during the UC-Stanford Big Game and only one intern was
available for each University service. For years afterward, attendance was taken
weekends to be sure that there was at least one intern available on all specialty
services.
Decisions regarding the need for hospital admission were nominally
made after communication with a house officer or resident. However, the interns
in the Emergency Department made most of the decisions once the academic
year was in its third or fourth month, after all interns had been “baptized”. The
decision to admit or discharge patients to a clinic was made with safeguards for
patients. The intern recipient of the admission was not loath to confront his peer
in the emergency room directly regarding his disdain for his colleague’s
competence—and an inappropriately discharged patient might be brought right
back by ambulance or referred back from an outpatient clinic with a critical
comment. If the worst happened and a catastrophe should occur after a patient’s
discharge, the press was ready with scandalous headlines.
The regular personnel on a surgical ward were one head nurse and one
orderly during the day. Before the San Francisco General Hospital (SFGH)
nursing school closed in 1932, there were student nurses on all the wards. They
assisted the chief nurse, and a senior nursing student covered one or more wards
at night.
The interns did all the “scut work”, including changing dressings,
starting intravenous lines (IVs) or clysis solutions (fluid therapy was commonly
given subcutaneously rather than intravenously—clysis). They set up the
nasogastric suction, by draining water from one gallon glass bottle into another,
creating suction for the nasogastric tube. Electrical suction machines did not
exist.
18
There was no such thing as an intensive care unit (ICU). Critically ill
patients who were perceived as salvageable by the head nurse had their beds
located next to the nursing station. Those dying and perceived as unsalvageable,
or those with overt infectious illness, were placed in the side rooms.
Supplemental oxygen was administered by tent, which was set up by the intern.
Blood gas assessment was not possible, so that cyanosis or extreme respiratory
difficulty was necessary before the need for
oxygen was recognized.
The interns did all transporting of
patients. There was no such thing as portable
xray machines, so the most common indication
for transport, was the need to take the patient
to the Radiology Department. The interns did
all the initial workup of the patients. A
detailed medical history and a physical were
the primary basis for diagnosis, and woe be it
for the intern who left out cogent details. As
most patients had been in the hospital before,
the first part of the evaluation consisted of
obtaining the patient’s old chart from the
basement “dungeon”, where the Record Room
was located, and summarizing all previous admissions.
Upon completion of the medical history and physical, the next step was
the laboratory work. All blood specimens were drawn by the interns. All patients
were tested for hemoglobin, white blood cell count, and a differential white
blood cell count based on the blood smear. Urinalysis followed, which included
tests for glucose, protein, specific gravity, and microscopic examination of the
urine sediment. If the patient had an infection, then a Gram stain of the drainage
was an essential part of the laboratory analysis. If the patient had diarrhea or
loose stools, a stool exam for ova and parasites was essential, as well as a
description of the stool. Because antibiotics did not yet exist, the primary reason
for bacterial studies was to identify pathogens that required isolation procedures.
These studies included smears for intracellular diplococci, which were
diagnostic of gonorrhea, black light studies for the spirochete of syphilis, and
acid fast smears for tuberculosis. Needless to say, these tests were time
consuming. Fortunately, there was usually a back-up technician who would
verify questionable smears and conduct appropriate cultures. However, this
service was available only five days a week during the daylight hours. Nights
and weekends the interns were on their own, backed up only by their residents.
EMERGENCY ROOM & CLINICS
The source of hospital patients at the County included those admitted
through Mission Emergency by ambulance or as walk-ins, those referred from
the City’s peripheral Emergency System, and those referred from the Stanford
and UC Clinics.
The first emergency room had been located in the basement of the City
Hall itself, but it had been destroyed in 1906 by the earthquake and fire. It was
rebuilt as Central Emergency as part of the Municipal complex and served as
headquarters for the City ambulance system. Until the mid 1930s, many major
surgical procedures, including major amputations, were done there by the chief
19
of the Emergency Service. As the City developed, emergency facilities were
built in the Harbor area and in Golden Gate Park.
Mission Emergency was established in 1909. Initially, it was located in
a separate building at 23rd Street and Potrero. In the 1930s, Alemany
Emergency was opened in the southwest portion of the City. Because of its
proximity to the County Hospital, Mission Emergency was physically
incorporated into the 1915 County Hospital building. As was true of the other
emergency facilities, it remained separate administratively from the Hospital.
During most of the period between
World War I and World War II, it was
run by two surgeons, Edmund Butler
and George Rhoads.
First aid, treatment of cuts and
lacerations, and medical and surgical
triage were done in the emergency
hospitals. Any citizen of San Francisco
could walk into one of these facilities
Butler and Rhoads
and be treated free of charge. However,
if hospitalization was needed, indigent patients were transferred by ambulance
to the County Hospital and private patients were referred to their local private
hospital.
Central Emergency stopped doing any major surgical procedures by the
mid 1930s, when it was apparent that the increasing medical sophistication of
the County Hospital provided a much safer environment for surgical care. Safe
surgical care was greatly improved when the blood bank opened in 1939.
Butler and Rhoads supervised Mission Emergency on alternate weeks.
Edmund Butler, the Chief of the Emergency System, had a Stanford clinical
appointment and took call during Stanford Emergency weeks. George Rhoads,
his partner in private practice, had a UC appointment and covered the UC
emergency weeks. Both surgeons would be notified of any case requiring
emergency surgery, but—except for a particularly demanding case, especially
one with political overtones—they would defer to the surgery resident for the
operation itself.
In addition to the emergency room, which was a major source of
patients, the UC and Stanford clinics were a common source of referrals. The
City had opted not to open outpatient clinics at the County Hospital, as both
Universities had clinics for the indigent. Both would admit the best teaching
cases to their hospitals, but the University Hospitals were small and funds for
hospital care of indigent patients were limited. The bulk of the patients needing
hospitalization were referred to the corresponding County University Service.
Thereafter, except for an urgent emergency case requiring, immediate surgical
care, patients remained a ward of the University Service that first admitted them.
It was not unusual for a busy intern to be found, late at night, in the bowels of
the hospital where the Record Room was located, looking to see if a “crud
admission” had had a previous admission to the opposite service. An occasional
cry, “Eureka, he’s a Stanford patient!” could be heard on a busy UC night.
20
SURGERY
Surgical technique
Before the introduction of anesthesia, surgery, of necessity, had to be
done quickly and was associated with what now would be considered gross
technique. By the end of the Civil War, in 1865, most physicians in the U.S. had
learned to use anesthesia, but surgical technique had changed little. While large
blood vessels were tied, mass ligatures were used frequently, and the cautery
was still used to facilitate hemostasis. Eloesser used the Percy cautery in his
major cancer operations through the 1930s. This was an electrical cautery
instrument originally devised for uterine work. It did not heat enough to char
tissues, but it was thought to cook tissues sufficiently to destroy any malignant
cells. For that reason, it was referred to as the “cold iron” method.
The reluctance to accept new techniques persisted in the 1920s.
Complication rates, particularly those related to infections, were abysmally high.
However, at Johns Hopkins Hospital, Halsted was demonstrating superior
results when a meticulous, atraumatic technique was used. By the late 1920s and
early 1930s, both UC and Stanford fell under the influence of the Halsted
method. Emile Holman, who had trained with Halsted and assumed the Chair of
Surgery at Stanford in 1926, was a rigid advocate. Glenn Bell, when he arrived
in 1932 to assume responsibility for U.C.’s General Surgery program, instilled
these concepts in his trainees, who included Leon Goldman and Horace
McCorkle. Because the Stanford Surgery program at the County remained
independent of, and somewhat isolated from, Holman’s influence, the Stanford
surgeons’ technique at the County evolved more gradually toward Halstedian
concepts, and was considered gross by the UC surgeons.
The Halstedian technique emphasized gentle handling of tissue;
meticulous hemostasis, especially in the subcutaneous tissue; the use of fine silk
sutures cut on the knot; closure of all dead space, including approximation of the
peritoneum as a separate layer; and closure of the subcutaneous tissue. It
included absolute bed rest, even for operations such as inguinal hernia, for
which ten days of bed rest was the standard.
There were no antibiotics at this time. Wound infections were common
and contaminated wounds, whether acquired in the hospital or the community,
were routinely left open. A ruptured appendix with peritonitis was usually fatal.
An inadvertent enterotomy was catastrophic. When a surgeon was working in
potentially contaminated areas, the tragic results of infection were always
paramount in the surgeon’s mind. When fever and systemic sepsis was manifest,
the concept was, “pus somewhere, pus
nowhere, look under the diaphragm,”
followed by complicated maneuvers to
drain the pus without contaminating the
rest of the peritoneal cavity. The
Clairmont anterior subcostal extraperitoneal approach and the Ochsner
posterior approach through the bed of
the 12th rib were classic ways to drain
perihepatic abscesses.
Hemolytic
streptococcal
infections, if not immediately fatal,
Typical Operating Room
often led to the long-term consequences
21
of rheumatic fever and glomerulonephritis. Wound infections that “pussed out”
had a favorable prognosis (usually staphylococcus), whereas those that had no
pus or were associated with serous drainage were fatal (streptococcus,
necrotizing anaerobic infections).
When the sulfa drugs became available in clinical use early in the
1940s, the literature was full of clinical studies of how to use them. Crystals
were dumped into wounds. When there was peritonitis, crystals were spooned
into the peritoneal cavity. The patients turned blue, their kidneys clogged with
crystals, but their improvement was often dramatic and deaths from septic
complications were significantly reduced.
Type of Surgery:
Before appendicitis was recognized as a clinical entity by Reginald Fitz
in Boston in 1886, typhoid fever was thought to account for peri-ceccal
abscesses, as ileal perforation was a common complication associated with
typhoid fever. By the 1920s, the appendectomy was becoming a far too
common operation. It was estimated that, in the 1930s, one person in five in the
United States was having his or her appendix removed. The scandal of “chronic
appendicitis” stimulated the institution of hospital tissue committees to review
normal organs being removed.
A close second in terms of abdominal operations were salpingectomy
and oophorectomy. Pelvic inflammatory disease was extremely common, and
chronic tubal infections could only be cured by surgical removal. Gynecologists
and general surgeons vied for the operation in this period. Repair of cervical
lacerations (trachelorraphy) after childbirth was an accepted and a common
procedure.
Hernias of all types were now being treated with surgery rather than
trusses. A Dr. Rosberg, a volunteer surgeon on the Stanford Service, had the
audacity to perform hernia repair on a patient under local anesthesia and then
walk the patient from the operating room back to his ward bed. This so
compromised the Halstedian principle of ten days of absolute bed rest that
Rosberg was dropped from the staff.
The major operations in the 1930s were gastrectomy for cancer and
ulcer disease, thyroidectomy for cancer and hyperthyroidism, and
abdominoperineal resection for rectal cancer. The gastrointestinal cases
represented the ultimate surgical challenges because any anastomotic leak
usually meant the patient would die. Operations for thyroid disease were risky
because the tumors were large and very vascular, or, in the case of
hyperthyroidism, thyroidectomy was associated with the risk of postoperative
thyroid storm. Emil Theodor Kocher, in Switzerland, had mastered the
operation, but his operations still had a 4% mortality rate. Abdomino-perineal
resection, although a major advancement in cancer treatment over local
fulguration, carried the risk of extensive blood loss.
During the 1930s, both Brunn and Eloesser were pioneering in the new
field of thoracic surgery. Tuberculosis, with its complications, was the number
one cause of death. Cavitary disease with hemorrhage and empyema were
frequent complications of tuberculosis. Pneumonia resulted in lung abscess,
bronchiectasis, and empyema. Lung cancer was usually far advanced when first
diagnosed and, less commonly than now, susceptible to surgical treatment.
22
Brunn pioneered lobectomy for cancer and bronchiectasis, in which—
instead of using mass ligature—he dissected and ligated the lobar arteries and
veins before dividing the bronchus. Eloesser devised the operation that provided
a solution for tuberculous empyema. This technique was to insert a flap of skin
into the pleura to keep the cavity open and prevent recurrent empyema.
Other types of cases treated during this period were wringer injuries of
the arm; many types of fractures; chronic skin ulcers; huge inguinal hernias;
abdominal tumors; oral cancers; big, fungating colon cancers; Ludwig’s angina;
all kinds of infections; and abscesses. Chronic osteomyelitis was a devastating
problem and was treated with debridement and open drainage.
Cholecystectomies and cholecystostomies were common operations. Tonsillar
abscesses were frequent complications of tonsillitis, especially during the winter
months. Tonsillectomies and adenoidectomies were done prophylactically on
most children.
SPECIAL PEOPLE
Harry Ricks
Harry Ricks was the last horse-drawn ambulance driver—the only one
who would go into Chinatown to pick up the plague victims.
Maggie Smith
Maggie Smith served as triage officer for Mission Emergency. Her
station was the only entry point for walk-ins. She was a large, stout, intimidating
social worker whose job it was to ensure that none but the truly indigent was
admitted. Certain types of semi-elective cases were rotated between the two
services if the admission was not a true emergency. If Ms. Smith was treated
properly, she might favor one service over the other when it came to referring
desirable cases. Ehler Eiskamp was advised—as he started as Stanford house
officer in 1922—to be sure and take Maggie to dinner from time to time.
Nathalie Forsythe
Nathalie Forsythe was the secretary for the University of California at
the San Francisco County Hospital during the 1930s and early 1940s. She was
“the nuts and bolts of the UC Surgical Service.” She was a southern belle and
spoke with a deep southern drawl. She had all the answers, pulled the strings,
made the arrangements, and did all the dirty work. Her spacious office was just
in back of Mission Emergency. It was also the central point for the UC visiting
faculty, as there were no full-time faculty members or faculty offices then. Her
office contained an old dictating machine on which operations were recorded for
her transcription. She assigned cases to the third-year medical students and
attended to their curricula. She shepherded the residents, too. After many
productive years she married a fireman and retired.
Walter Whitehead
Walter Whitehead, the morgue man, whistled and blew as he pushed
his gurney to the morgue. He had a hole in his chest you could put two fists
into, all crisscrossed with trabeculae and half-opened cysts.
23
Oley
After Whitehead came Oley. He was also the grand gentleman in
charge of dead bodies in the morgue. He spoke with a broad, Swedish accent;
wore boots, a leather apron, and a hat; and sported a drooping mustache. He
inhabited the dimly lighted bowels of the building where ran the exposed pipes
and ducts. You could hear his clump, clumping down the long, dark hallways
where, as he passed under a dim bulb, and catch a glimpse of him pushing a
gurney on which lay a supine body outlined by the white sheet that covered it.
He did the dirty work at autopsies.
Toby Bost
Toby Bost, one of twins, was the chief of UC Orthopedics at the
County in the 1930s. He was not much over five feet tall, but he had a very
aggressive personality. His brother was a pediatrician. At that time, general
surgeons operated on all the fractures and orthopedists did the reconstructive
surgery.
Edmund Butler
Edmund Butler was graduated from Stanford in 1911. He had his
internship and residency training at Stanford from 1911-1914. His private office
was at 490 Post Street. His administrative headquarters were at Central
Emergency. He recruited and hired all personnel, including ambulance staff. He
was a good surgeon, an excellent teacher, and a nice man personally, according
to one of his house officers. He was appointed Chief of the City-wide
emergency and ambulance system in 1919 and served until his death in 1954.
The job as an emergency physician was perceived to be a plum in
which a young surgeon—all emergency room staff were surgeons—could earn
income while building a practice. Butler gave graduates of the County surgical
program preference for these jobs, and most of those who elected to stay in San
Francisco signed on.
George Rhoads
George Rhoads obtained his B.S at UC and his medical degree from
Johns Hopkins in 1915. He interned in surgery at Johns Hopkins from 19151916. His residency was at Roosevelt Hospital in New York from 1917-1918.
He spent a year in the English ambulance service in World War I, from 19161917. He came to San Francisco in 1920, where he joined Edmund Butler in
practice and was appointed assistant professor at UC and assistant chief of the
Emergency Service.
As mentioned earlier, he and Butler alternated weeks covering the
emergency system, which included Mission Emergency. The residents
considered Rhoads a fine gentleman and an outstanding teacher. He was
described as a kindly man with a ready smile. He was admired by all the
residents who served under him on the emergency service.
When World War II started, he was appointed chief of General
Hospital 330, a UC medical unit. He served as chief from 1942 until his
untimely death from hepatitis in London in 1944.
24
INCIDENTS & ANECDOTES
War Surgery at San Francisco Hospital
Examiner 6-18-18: “War Surgery is used in SF Hospital. Methods of
‘West Front’ surgeons save the leg of a youth injured in San Francisco. Ward B
of the City institution used to teach civilian and army doctors. Pedro, age 3, had
his foot crushed by a motor truck. Carrel-Dakin’s solution used—foot saved!”
Medicinal Alcohol
Before the end of prohibition in 1933, the housestaff still managed to
party. A physician could order spirits for medicinal purposes. Accordingly, “we
might write a prescription in the name of a patient once a month and get a quart
of very nice bonded whiskey. It was not much but added to the merriment of
many parties.”
Grateful Rum Runner
“Once I had a patient who was a rum runner. In gratitude he presented
me with a very large bottle of rum. This called for a party and resulted in a large
gathering in anticipation of the libation. We opened the bottle and the one who
took the first drink promptly spat it out and almost choked. It tasted like
concentrated creosote!”
Near, Really Near Beer
“It was discovered that you could add 100% pure laboratory alcohol to
the empty space in a bottle of near beer and come up with a very satisfactory
beverage.”
The Longshoreman Strike
“On July 1, 1934, just as I became chief resident, the strike started with
a bang. Four days later the ‘Battle of Rincon Hill’ occurred and one day after
that, the strike became general. The first test on July 3rd came when the police
cleared pickets from in front of Pier 38. As trucks attempted to leave the pier
they were met by a large group of strikers who were repulsed by tear gas and
night sticks of the police. Thirteen police and a dozen strikers were the
casualties.
“Two days later, July 5th, ‘bloody Thursday,’ thousands of striking
longshoremen and other maritime workers roamed the embarcadero turning over
trucks, attacking strike breakers, burning goods and clashing with the police.
More than 100 were seriously wounded or burned. Mission Emergency served
as the front line for the wounded. The ambulances shuttled back and forth from
the battlegrounds. We set up outside triage deciding who needed to go
immediately to surgery, who had to be observed and who could be sent to other
hospitals. We opened two new wards, one for the police and the other for the
strikers.
“The deaths of two workers turned public sympathy toward the strikers.
There was a solemn funeral procession in which 10,000 workers marched up
Market Street. All accesses to the city were closed; all stores were closed.
Practically all activities of a busy city were called to a halt before the strike was
resolved.”
25
Painted Toenails
“There was always a problem of differentiating pelvic inflammatory
disease (PID) from appendicitis in females. There was an aide in the ER who
claimed she could identify PID, by noting whether or not the patient had painted
toenails. She was usually right.”
Overpaid Chief
“As executive chief resident I made $90 per month. I had to sign my
name so many times that year I am sure it will never be a collector’s item. I
commandeered a large empty room on the first floor, found a desk and chair,
hung pictures on the wall, and had my office.”
A Case of Paraplegia
Eloesser’s dachshund developed transient paraplegia of the lower
extremities, as this type of dog tends to do. Eloesser had the dog admitted to St.
Luke’s hospital to a private room.
The San Francisco Examiner
Leo Eloesser had no liking for the Hearst newspaper. In one instance,
when in the process of changing a dirty, smelly dressing on a patient with
tuberculosis empyema, he said to the nurse, “Please, Mrs. Fuller, get me an
Examiner for these dressings.” After some time, she returned with the San
Francisco Chronicle. “Doctor I am sorry, I could not find an Examiner.” Leo
assured her that it was all right, “but I do hate to put these dirty dressings in a
Chronicle”.
Teach by Example
Eloesser loved to teach by example. The senior students were allowed
to assist in surgery, but were sometimes reluctant to spend ten minutes to scrub
their hands and arms. He would tell the students that bacteria were invisible and
much smaller than particles of soot, and should be washed from one’s arms and
hands before surgery. To prove his point, he had the student immerse his arms
and hands in a pot of soot with instructions that he join the operation when his
hands were clean. Invariably the student would still be scrubbing when the
operation was finished.
Student Teaching
“At our first session, Eloesser called on a student to present the case
that he supposedly had worked up in detail. He was quizzed about details
concerning the heart, lungs, abdomen, rectum, and neurological status, including
the patient’s gait. The student was very glib with his answers, particularly
emphasizing that the gait was normal. With that, Eloesser pulled back the sheets
to disclose, to the presenter’s chagrin, that the patient had only one leg.”
Contaminated Bullets
Once, while Eloesser was operating with his resident on a gunshot
victim he asked, “How high does the muzzle velocity of the bullet need to be to
sterilize the bullet?” When the resident expressed ignorance, Eloesser
responded: “Well, when I was in Germany they were experimenting with
26
bacterial coated bullets, and they had us run experiments with the various
muzzle velocities to find out what speed sterilized them”.
Eloesser’s Rounds
“Although I trained on the opposite service, I always tried to find time
to go with the Stanford group on Eloesser’s rounds.”
Eloesser and the Greek
A Greek patient had burns of his scalp, from ear to ear, from his
forehead to the nape of his neck.
Eloesser: “What’s wrong?”
Patient: “Burn.”
Eloesser: “Yes, I see. How come?”
Patient: “My friend burn me.”
Eloesser: “What for?”
Patient: “He burn me for funny. Ha Ha.”
Eloesser commented, “The Greek and I became long-time friends. He invited
me to the Greek Orthodox baptism of his daughter.”
A Startling Event
“I was startled to see Eloesser pushing down the hall a patient with an
open chest. It seems that he was taking the patient to xray for open treatment of
his lung cancer.”
Christmas Dinner
Harold Hill, the chief of Stanford Medicine at the County, was invited
to a Christmas dinner given by Eloesser’s mother and father. Most of the
members of the Eloesser family were there, but not Leo. Hill wrote, “We had an
excellent dinner and, just about the time we finished the turkey and dressing,
Leo appeared. He kissed his mother and father and disappeared into the kitchen,
soon coming back with a large basket with the remains of the turkey in it, along
with whatever else he could find in the kitchen.”
He said “I am sorry I can’t have Christmas dinner with you, but I have
some patients in the Mission that are not going to have any dinner tonight unless
I bring it. Merry Christmas!”
A Sad Surprise
No one suspected that Miss W, an operating room nurse, had been
pregnant for nine months. She had the baby after she got off duty one day, and
threw it down a laundry chute, where it was found the next morning among the
bloody linens. The poor woman was discharged. Someone was heard to say,
“Can’t have such goings on, even in the County Hospital”.
What a Whirligig
“A woman intern who masqueraded as a man shared her room with a
male intern who swore he never knew!”
Ward M
The chief resident was responsible for the prostitutes’ ward. Prostitutes
who tested positive for venereal disease in one of the community clinics were
27
ordered by judges to be confined to Ward M. They remained confined until three
successive cultures for gonococcus were negative or until they had completed
arsenical and bismuth treatment for syphilis. The ward was a jungle, and it
required stout matrons and big-muscled orderlies to maintain any kind of
discipline.
In 1924, the inmates succeeded in binding and gagging the staff one
evening and escaped in their hospital gowns. The ward was so notorious that,
when antibiotics became available and the ward was no longer needed for
prostitute incarceration, its name was changed to Ward W—which, of course,
was out of alphabetical sequence with the rest of the wards.
Eloesser’s Special Autopsy
Eloesser wrote, “My first autopsy at the County Hospital; I carried the
body of ‘Little Egypt’ to the morgue myself. ‘Little Egypt,’ the original belly
dancer, a little redheaded Irish woman. Dead of pancreatitis. The famous ‘Little
Egypt’ wiggled her gold-spangled umbilicus about in the Midway of the
Chicago Columbian Exposition in 1893. Poor ‘Little Egypt’ of Bella Union
Theatre, the burlesque shows and the basement dives of upper Kearney Street,
dead and forgotten.”
First Case
“During my UC residency, I was in my sixth postgraduate year (19441945) before I did my first major case. Up until that time we assisted our
professors or our chief resident, who in his final year did everything from
hernias to major thoracic procedures.”
Cut Throat
“Our babysitter responded to a knock on the door of our apartment to
find a somewhat disreputable-looking Chinese man carrying a large gunny sac.
He apparently could not speak English, but managed to say ‘Dr. Mathewson
he’—then he ran his finger across his throat. He was trying to indicate that
Mathewson had operated on his thyroid, but she misinterpreted this, screamed,
and tried to close the door. Just before she succeeded in doing so, he tossed the
sac through the door. Thinking it was a bomb, she immediately tossed it out the
window expecting an explosion. The sac however seemed to come alive which
resulted in more screams. It turned out the sac contained a live chicken that my
patient had brought as a gift.”
Escape
“An ex-convict, shortly after his release from prison, attempted to rob a
night watchman. However, the victim had a gun and managed to empty his
revolver into the right upper quadrant of his assailant. We managed to fix the
liver injury, but the patient required close nursing attention on the surgical ward.
He was guarded 24 hours a day, was extremely obnoxious, spat on the nurses,
and cursed his guard. One night when I was working late, I saw, out of the
corner of my eye, the prisoner sneaking the bathroom carrying the sheets from
his bed. As soon as I saw him disappear into the bathroom, I ran to what
appeared to be his inattentive guard and asked: “Didn’t you just see what he
did?”
“Yes I did,” responded the guard.
28
“Why didn’t you stop him? He is going to tear the sheets make a rope
and climb down out of the bathroom.”
The guard said, “Don’t worry son, he won’t get more than halfway.”
Attached to a Chair
There was a little old lady who was so short of breath that she had to sit
up to breathe. Her family arranged for her to sit in a wicker chair. They cut a
hole in the bottom and put a pail underneath to care for her bowel and bladder
needs. After a number of weeks, they decided that she was not getting better and
an ambulance was called. When they tried to lift her out of the chair the chair
came with her and she cried out whenever they tried to pull the chair from her.
They transported her to the hospital in the chair. When the nurses took her
clothes off it was apparent that the chair had eroded though the soft tissue to the
bone, and the chair was fixed in place with exuberant granulation tissue.
CASES
Carcinoma of the Breast
Rixford reported four cases of breast cancer in which he resected the
chest wall. No endotracheal anesthesia was used. He slipped a wet towel into the
chest to occlude the opening and prevent collapse of the lung. He had no
problems with an open pneumothorax.
Streptococcal Infection
“I was engaged in a long operation when I got a call that one of my
fellow interns, Mo, was ill in the infectious disease ward. At the completion of
the case I called the ward and was informed that Mo was desperately ill. It
seemed that he had spent the night with a patient who died that morning from
streptococcus septicemia initiated by a strep throat. Mo apparently picked up the
same organism and was raving with fever from the disease. With the protection
of a mask, gown, and rubber gloves, I assisted in restraining him, but was
otherwise helpless to keep him from dying within my grasp. One of the hardest
tasks of my life was to pronounce him dead and offer solace to his mother and
father.”
A Transplant First
There was a former prize fighter, “Buck Kelly,” who—after shooting a
taxi driver and commandeering the taxi—went on a crime spree, shooting a
number of innocent people. He was finally trapped by the police and shot in the
abdomen. His abdomen was tender and we told him that he would die if he did
not have an operation. He refused. Later we found that the bullet had bounced
off his ilium and encircled his trunk and was lying in the subcutaneous tissue.
After a suitable trial, he was condemned to be hanged. It happened that
the San Quentin physician at the time, Dr. Stanley, claimed that he could
revitalize impotent men by transplanting fresh testicular tissue from fresh
cadavers. A young urologist at the University of California arranged to obtain
the tissue immediately after Kelly’s death. I understand this tissue was
transplanted into a prominent individual. The outcome of the operation was
never reported.
29
Bronchopleural Fistulae
There were always patients with chronic tuberculosis around who had
bronchopleural-cutaneous fistulae; most often this condition followed the
drainage of a tuberculous empyema. These poor souls were condemned to a
lifetime of institutional care. “We attempted to treat them by collapsing the chest
wall down on the residual space (thoracoplasty). In one period, we attempted to
cauterize the fistulae through the open chest by using silver nitrate sticks. To
locate the more obscure fistulae, the patient would hold his or her nose, close the
glottis, and strain. The fistulae would bubble and whistle.”
Missed Injury
“When I was a green intern in the emergency room, a man who had
been in an auto accident was admitted whose body had been perforated by
dozens of shards of glass. I spent the evening picking out the glass, cleaning and
closing numerous wounds. The next morning I showed him with pride to Dr.
Eloesser who inquired about further injuries. He then proceeded to examine the
patient himself and found an obvious posterior dislocation of the hip. I learned
an important lesson in life. Do not be distracted by obvious injuries. Always do
a thorough examination. An obvious injury may mask a more serious one!”
A Numb Arm
A man injured in a high-speed chase was brought into the emergency
room by the police. He was holding his arm, which he said was numb. When we
removed his coat, his arm came with it. It had been completely severed below
the left shoulder.
T and A’s
During the summer months and school vacations there would be a vast
number of poor little children lined up in the operating room corridor awaiting
tonsillectomy and adenoidectomy. About 20 or more of them were done each
morning before the regular surgical schedule started. We had two rooms devoted
to this purpose, one for the ENT resident and one for the surgical resident. The
patients would be brought in already anesthetized, their tonsils and adenoids
would be removed, and then they would be wheeled out and the next one
wheeled in.
Infected Wounds
“We treated badly infected wounds in casts. Often when the casts came
off, the wounds were crawling with maggots. We specially raised them to
prevent tetanus and then put the little buggers in the wound, covered them and
left them. Carrel-Dakin solution (sodium hypochlorite) was used by continuous
drip on other infected wounds.”
Wringer Injury
One of the standard injuries in the 1930s and 1940s was the wringer
injury. The early washing machines came equipped with two rollers, which
compressed wet wash and removed most of the water. In the course of feeding
the wet wash into the rollers, it was easy for the hand to be caught in a relentless
grip that pulled the arm up to the elbow or to the axilla. As this happened, the
30
skin and subcutaneous tissue were stripped from the underlying arm. The skin
was often so badly mangled that the rule was to remove the flaps of skin that
were generated, de-fat them, and replace them as full-thickness skin grafts.
Sometimes they took and sometimes they did not.
Open Drainage Tuberculosis
“During my chief resident year, the UC Service embarked on the study
of Monaldi drainage to treat tuberculosis cavitary disease. This process
consisted of percutaneous suction drainage of the cavities. When I think of the
risk to housestaff and students, I shudder!”
Hiccups
“We had a poor patient who had ‘hiccups’ for 40 days in spite of every
medical and surgical measure we could think of. He finally burst out of the
hospital and ran in front of a car on Potrero Avenue. That cured his hiccups but
the hard way.”
Ascites Bank
“We banked the ascitic fluid that we drained regularly from jaundiced
patients with ascites sometimes referred to as “’yellow pumpkins’ by the
housestaff. We used it to treat shock and malnutrition.”
Empyema
Empyema was a common and often deadly complication of lobar
pneumonia, the most common cause for medical admissions during the winter
months. The surgeons’ role was to drain empyema cavities. This most often
consisted of tube drainage, but open drainage with an Eloesser flap was used as
well. Before the introduction of antibiotics, decortication of a chronic cavity was
rarely used.
Assisting Leo
“Because of my interest in thoracic surgery, Carl Mathewson—whom
we called Matty—would occasionally assign me to assist Leo Eloesser in his
private surgery. Leo would pick me up at the County in his big Buick
convertible and take me with him to St. Joe’s. The top was always down, rain,
fog, or shine. My white suit would often turn into a wet dishrag.”
Rounds with Eloesser
“Dr. Eloesser enjoyed making rounds with the surgical housestaff. The
only trouble was that they were usually at 4:30 A.M. One morning we made
rounds on a Chinese fellow with horrible ulcers on his feet. Neither the intern
nor I was able to obtain a history for the man. None of the Chinese interpreters
could understand him, and he spoke absolutely no English. Leo took a special
interest in the case and was able to speak to him in his dialect. Because Eloesser
was so short, he actually climbed in bed with the man to examine him. Finally
he said: ‘Boys, what’s the diagnosis?’ We had no response. He said: ‘This man
has Hansen’s disease. Feel these enlarged epitrochlear lymph nodes; look at
these ragged ulcers. If you had taken a history you would have found that he
comes from an area of China where leprosy is endemic!’”
31
The German Consul
A Wet Clinic was put on for the American College of Surgeons
meeting. The large third-floor amphitheater at the County was filled to capacity.
Eloesser elected to operate on the German consul to resect a huge lung tumor as
his demonstration. In this period, his operation consisted of mass ligature of the
lung hilum with distal lung amputation. Just as the lung was divided and
removed, the ligature slipped off the hilum, and massive hemorrhage ensued.
The patient died on the spot! The nonplussed surgeon announced:“Gentlemen,
we will now start the autopsy.”
Splenectomy
In preparation for another American College of Surgeons meeting, Carl
Mathewson—then a junior professor—was asked to select a case as a warm up
for the main operation to be done by Eloesser or Brunn. A week or two before,
Mathewson had done a cholecystectomy on a patient with a splenic hemolytic
disorder. In the course of that operation, he reached over and palpated what he
found to be a large mobile spleen; he could nearly pull it up into his right
subcostal incision. “An ideal case!”
Several weeks later, equipped with a microphone around his neck, he
was ensconced in a rapidly filling amphitheater with an audience eager to see
the professor’s case, which was to follow. Much to Mathewson’s horror, when
he attempted to expose the spleen, he found it bound down by numerous dense,
vascular adhesions. Forgetting the microphone in the course of the dissection, he
uttered several swear words under his breath. The audience burst out laughing.
He—thinking they were laughing at his difficulty—let out a stream of expletives
under his breath, only to be greeted by a downright roar of laughter. Fortunately
someone came up, tapped him on the shoulder, and informed him that he was
being broadcast. Worse yet, by this time his hour was up and the main event
displaced him into the hall, where he had to complete his operation.
Plastic Surgery
“A tough policeman I knew brought in a roaring drunk Swede,
handcuffed and bleeding from overt facial trauma. On examination I found
numerous lacerations of his face, which I proceeded to sew up. He also had a
terribly misshapen nose, bent over to one side of his face. I took the heel of my
hand and gave the nose a real hard blow and pushed it back to the midline. I then
proceeded to pack the nostrils and put adhesive across his nose. I was quite
pleased with the result. The next week he returned to the emergency room
demanding to see the doctor who set his nose. As I was apprehensive about his
response to the care I had provided, I said that the doctor who was out. “Oh, I
am sorry, I came to thank him for straightening my nose; it has been bad for 20
years and I wanted to give him a little present in appreciation.”
SUMMARY
The period between 1915-1945 represented the flowering of Surgery
throughout the United States. Although aseptic principles had evolved with the
turn of the Century, surgical technique remained quite crude, changing gradually
during the 1920s and 1930s. Rough surgery was accompanied by a high
incidence of wound infection, breakdown of gastrointestinal anastomoses, and
resultant fatal peritonitis.
32
Peritonitis from a ruptured appendix or gall bladder was most often
fatal, as there was no such thing as antibiotics. The key to preventing this and
other life-threatening infections lay in early diagnosis and meticulous surgery.
Advances in surgical technique during this period were stimulated by
exposure of senior staff to the German School of Surgery and by the example
being provided by Halsted at Johns Hopkins University. Brunn and Eloesser, the
Chiefs of the two University Surgical Services, had received part of their
surgical education in Germany, and the leaders of the Surgery Departments at
the University of California and Stanford University had been trained in the
Halsted method, which emphasized atraumatic dissection and meticulous
hemostasis. As the result, surgery became much safer because of a marked
decrease in wound infection and improved wound healing.
These developments were reflected in San Francisco City and County
Hospital by the expansion of gastric, biliary, colon, and thyroid surgery.
Moreover, Brunn and Eloesser participated in the development of the new field
of thoracic surgery. Brunn was the first to perform lobectomy, utilizing
definitive ligation of the major pulmonary vessels and bronchus. Eloesser
pioneered in the treatment of inflammatory disease, which included tuberculosis.
He developed a unique method of drainage of chronic thoracic infection, using a
flap of skin to keep the cavity open.
Specialty training was negligible at the beginning of this period. Oneyear rotating internships constituted the maximum training for most medical
school graduates, and most surgery in the United States was performed by
physicians without extensive training in a broad range of disorders than could be
treated surgically. After advances in anesthesia, asepsis, and finer surgical and
related techniques occurred, the Age of the Surgeon emerged, as major lifepreserving operations became possible, when performed by trained surgeons. As
the result, in San Francisco, formal training programs in surgery, based
primarily at the County Hospital, were organized by both the University of
California and Stanford University in the early 1930s. These training programs
emphasized accurate diagnosis and dedicated preoperative and postoperative
care, in addition to good surgical technique. As the graduates of these programs
entered practice, they set the standards for surgery in the Western United States.
33
UNIVERSITY OF CALIFORNIA STAFF
Resident Physicians—Administrators
1923 Frank Shelly
1929 Daniel Collins
1930 Martin Debenham
1931 Harry M. Blackfield
1933 Ray Millzner
Resident Trainees—Combined Program under Dr. Glenn Bell
1934 Leon Goldman, Jack Nicholson
1935 Charles Rosson, Dudley Saeltzer
1936 Walter D. Birnbaum, Jacob O. Smith
1937 Jacob O. Smith
1938 F. Harry Benteen, John M. Fernald, Clayton G. Lyon
1939 Horace J. McCorkle, Maurice L. Zeff
1940 Maurice J. Brown, Clinton V. Ervin Jr.
1941 Edwin G. Clausen, Ralph D. Cressman, Sanford E. Leeds
1942 R. Bruce Henley, Harry E. Peters Jr.
1943 Marshall W. Johnstone, Henry L. Silvani
1944 William Brock, Stanley G. Johnson, E. William Rector
1945 None listed
STANFORD UNIVERSITY STAFF
Residents Physicians—Administrators
1926 Everett Carlson
1928 Raymond Scott
1930 Artemus Strong
Resident Trainees San Francisco County Hospital
1935-1936 Milburn H. Querna
1936-1937 W. Wallace Green
1937-1938 Cecil Cutting
1938-1939 Louis Huff
1939-1940 Russell R. Klein
1940-1941 Bert L. Halter
1941-1942 Roland Pinkham
1942-1943 John M. Buehler
1943-1945 Otto Tuscha
34
CHAPTER II
THE MATHEWSON–GOLDMAN–YEARS: 1945–1966
The period between World War II and the introduction of Medicaid and
Medicare in 1966 was the apogee of the strength and influence of county
hospitals on American medicine. During that time, most of the medical students
in the United States had most of their training in a county hospital. Philadelphia
General Hospital, Charity Hospital in New Orleans, and Los Angeles County
Hospital all had between 2,000 and 3,000 beds. San Francisco City and County
Hospital—affectionately still referred to as “the County” even though its name
had been changed to San Francisco General Hospital (SFGH)—had 1,300 beds.
Although supervised by a non-paid volunteer attending staff, the interns
and residents—the housestaff—had the ultimate responsibility for day-to-day
patient care. The strength of most of these programs was in their rotating
internships, as residents in specialty training in 1945 still constituted a relatively
small percentage of the housestaff. As had been true since 1915, the two medical
schools in San Francisco, Stanford University and the University of California
(UC), shared staffing of the San Francisco City and County Hospital. Each had
separate specialty services at the County and assumed responsibility for staffing
them. This arrangement lasted until 1960, when Stanford moved its medical
school from San Francisco to Palo Alto and gave up its responsibility for the
hospital.
With the end of World War II, it was necessary to upgrade the training
programs and staffing in the hospital because of advances in medicine and
surgery that were an outcome of the War. Before World War II, general practice
surgeons who had little or no formal training did most of the surgery in the
United States. New developments in surgery and anesthesia stimulated by the
war—such as a better understanding of shock, resuscitation, and blood
35
transfusion and the introduction of antibiotics—made surgery safer and led to
the potential for marked expansion of the discipline. In order to take full
advantage of these developments, reorganization and expansion of surgical
training was required.
In 1946, Leon Goldman, the executive officer and assistant chief of the
County’s UC Surgical Service during the War, was promoted to chief of service,
relieving Horace McCorkle, who had served the previous two years. Carl
Mathewson, who had just returned from the War, was appointed chief of the
Stanford service at the County to succeed Leo Eloesser. Roy Cohn, who had
served with Mathewson during the War, was recruited as Mathewson’s deputy.
The first order of business for Goldman and Mathewson was reestablishing the residency training program, which had been makeshift during
the war. The second challenge involved obtaining resources from the City and
County of San Francisco to support the additional residents needed to permit
expansion of their programs. They also needed to sort out the legacies of the
residency, the men returning from the War who had dropped out of training at
variable times to serve during the War. This had resulted in more residents being
promised positions than there was funding available to support them. However,
thanks to the GI Bill, which provided educational funds to veterans, those who
were ex-servicemen could subsist on this resource while waiting for the County
to fund their positions.
THE PROFESSORS
Carleton Mathewson, Jr.
Mathewson was chief of the
Stanford Service from 1945-1960. In
1960, after Stanford moved to Palo
Alto, the University of California
(UC) took professional responsibility
for the County hospital and offered
Mathewson the position of UC
professor of Surgery and chief of the
UC Gold Surgical Service, which
formerly had been the Stanford
Service.
Mathewson
accepted,
changed his allegiance, and ran this
UC Service at the County until his obligatory retirement at age 65.
Mathewson’s mother and father were both physicians who had met and
married at Cooper Medical College, which became Stanford Medical School in
1908. Carl, the second of three children, was born in Calistoga, California in
1902 while his father was doing a locum tenens. He was raised in Fresno, where
his father was the City Health Officer.
Mathewson entered Berkeley at age 17. After one year, he transferred
to Stanford, where he received his B.A. in 1923 and his M.D. in 1927. He then
enrolled in the rotating internship at the County and spent the next year (1927–
1928) as a Stanford surgical house officer. Emmett Rixford was the chief of
Surgery of the County Stanford service—from him Mathewson learned
36
technical expertise. Leo Eloesser was the assistant chief of Surgery at
Stanford—from him he learned clinical acumen.
In the 1920s, there was only one chief resident for all
specialties at the County, inevitably a surgeon. It was the custom to rotate the
chief resident position between UC and Stanford in alternate years. The year
Mathewson completed his surgical house officer training in 1929, it was UC’s
year to provide the chief resident. However, Eloesser, a good friend and
personal physician to the Director of Public Health, intervened to get
Mathewson appointed chief resident for the year instead. Mathewson’s irregular
appointment caused a major uproar that reached the governor’s office. The result
was that Mathewson’s appointment was revoked and he was abruptly out of a
job.
Mathewson was interested in orthopedics. He applied and was accepted
at the University of Iowa, where he spent six months training with Arthur
Steindler. He next took a position at Wilkie’s clinic at the Royal Infirmary in
Edinburgh for six months. Finally, he took Eloesser’s advice and moved to
Germany, where he assiduously memorized a speech in German and earned
himself a position with Nicolai Guleke, the head of the University Surgical
Clinic in Jena, where he found the ideal professional relationship. He remained
in Jena from 1930-1933, by which time he had become Guleke’s chief assistant.
Katherine Daly, his fiancée, joined him in Germany, where they were married in
1932.
The political situation in 1933 became increasingly uncomfortable for
Mathewson in Hitler’s Third Reich. Rixford, chief of the Stanford Surgical
Service, retired as chief of service at the County in 1932 and Eloesser was
appointed his successor. When Eloesser invited Mathewson to be his junior
associate at the County, Mathewson gratefully accepted and returned to the
County as assistant chief of the Stanford Surgical Service.
Mathewson worked full time at the County and was given a Stanford
University appointment as assistant professor. As part of his appointment, he
was provided a private office at Stanford. He also assumed responsibility for the
Municipal accident patients on Ward I at the County. As assistant chief of the
Stanford Service, he drew a small salary and supervised residents and medical
students.
With the onset of World War II, Stanford organized a medical unit, the
59th Evacuation Hospital (59th Evac), and Mathewson joined as its chief of
Surgery. This unit was mobilized in 1942 and served first in North Africa, then
in Sicily, Italy, France, and Germany. By the time Mathewson was discharged in
1946, he had been promoted to a full colonel and had been awarded the Legion
of Merit, the European-African campaign medal, and five campaign stars.
On his return from the War, Mathewson was welcomed back to the
Stanford Medical School faculty and was appointed associate professor and later
professor. He was given a private office at the Stanford University Hospital,
which he shared with Roy Cohn. Even so, there was no thought of integrating
the County surgical residency with that of the Stanford University Hospital. The
relationship between the two training programs had been negligible during
Eloesser’s tenure, and Emile Holman, chair of the Stanford University
Department of Surgery, saw no need to combine the programs. Those at
37
Stanford thought they had the better program. Those at the County knew theirs
was better.
Shortly after his return to San Francisco, Mathewson was appointed
Secretary of the American Board of Surgery. The American Board of Surgery
had been formed in 1936, but the certification of surgeons and of training
programs—decided upon in 1937—had not been initiated. Mathewson played a
major role in implementing the standards for training and qualifications for
Board certification. The length of training was set at a minimum of four clinical
years or three years plus a preceptorship with a Board-qualified surgeon.
As had been true of his predecessors, Professor Mathewson—Matty, as
he was affectionately known—spent all day Wednesday at the County.
Occasionally, during Wednesday rounds, he would select a patient to operate
on—one needing pancreatic, biliary, or esophageal surgery, his areas of interest.
He would operate or assist residents with difficult or unfamiliar cases, if
requested.
Although Matty was demanding of his residents, he was respected and
represented a father figure to them. Once Matty believed in a resident, that
resident knew he would be supported to the outside world through thick and
thin. For example, once one of his residents was being disciplined by the County
Hospital administrator for hitting a reporter who had compromised the privacy
of a female patient in Mission Emergency. When Matty heard that the resident
had been fired, he insisted that the resident’s story be reviewed, and when he
heard the details, he passionately exclaimed, “By God, I would have killed the
bastard.” This effectively ended any thought of disciplining the resident. Matty
also found jobs for his residents when they finished training, even stretching the
truth, if necessary, to help secure a position for them. As a result, his residents
admired him and were loyal to him.
Roy Cohn
Roy Cohn, assistant chief of the
Stanford Surgical Service, was the faculty
member the residents had the closest contact
and identification with. He always seemed to
be around. Cohn also had a University
appointment and a private office at the
University Hospital.
Cohn was born in 1909 in Portland,
Oregon, where his father was a businessman.
He was the youngest of twelve children.
Shortly after his birth, the family moved to
Los Angeles. Early in high school, Roy was
identified by Stanford psychologist Lewis M.
Terman as a gifted child, and at age 14 years
he was offered and accepted a scholarship to Stanford. After three years of
college, he entered Stanford Medical School. Because of his young age, he had
missed all of the social activity usually associated with high school and college.
The exception was tennis, which he loved and pursued for the rest of his life.
Cohn completed his M.D. degree at Stanford in 1929 and took a
rotating internship at the County. He had impressed William Dock, a famous
38
internist/pathologist at Stanford, and Dock helped him obtain a residency in
pathology under Mallory at Massachusetts General Hospital (MGH). After a
year, Mallory helped him secure a job in neurosurgery, working with William
Jason Mixter. Cohn impressed the chair of Surgery, Edward Churchill, and was
accepted for four years of surgical residency. He was the first Jew to be
appointed chief surgery resident at MGH
After completing his residency, Cohn returned to San Francisco and
was offered $200 a month to supervise student teaching at the County.
Mathewson, whose job it had been, was now extremely busy in private practice.
Cohn saw patients in an office at the University one or two afternoons a week.
His private practice did not flourish, and most of his clinical activity at Stanford
consisted of covering the practices of other surgeons when they were out of
town.
In 1939 Emile Holman, the chair of Surgery at Stanford, was asked to
nominate someone to start a new hospital in Bombay, India. As the job paid
what was then a high salary of $800 a month, Cohn volunteered and received
Holman’s endorsement. After succeeding in his mission, he returned three years
later, in time to join the 59th Evacuation Hospital, then being organized by
Mathewson. During World War II, Cohn was known for his superhuman ability
to turn out work. In one continuous night and day effort in France, he personally
treated more than 200 battle injuries—an unbelievable accomplishment, unless
one had seen him work.
After the War, Cohn accepted Mathewson’s former job as assistant
chief of the Stanford County Surgical Service. Cohn covered Mission
Emergency seven days a week during Stanford’s emergency week, missing only
a day or two if it was in conflict with an important surgical meeting. The
residents called him on all cases where an operation was necessary. As there was
no paging system, the challenge was how to locate Cohn. The residents soon
learned his schedule, and during daylight hours—if he was not in his private
office or at the County—he usually could be located at the California Tennis
Club.
Roy always seemed to be around and was the ultimate consultant. He
would always come when requested—and he had a knack of showing up at the
right time whenever he was needed. He could smell out pathology and make
diagnoses over the phone. When Roy was present, it was necessary to keep the
operation moving or he would step in and take over. Most of the residents loved
him, but the occasional resident who did not fit his mold was in trouble—was
given little leeway and lots of hands-on supervision.
Most medical students were afraid of Cohn, but when he had a group of
students he liked, he would spend a lot of special time with them and regale
them with war stories. These were fascinating sessions. Roy enjoyed dissecting
wartime generals—he knew General George S. Patton and disliked him
intensely—and he had visited German concentration camps and described their
horror.
Cohn could not tolerate verbosity. Residents rapidly learned that their
presentations should be short and to the point. He had a sarcastic sense of humor
and “you knew that he liked you when he used it on you.” Sarcasm without
humor, however, meant trouble.
Cohn felt his Jewish background strongly but never confided why.
Shortly after World War II, he met and married a lovely nurse—Ruth Wood.
39
When his children were born—four boys and a girl—he insisted they carry their
mother’s name rather than his own.
Unfortunately for the San Francisco program, Cohn elected to move to
the new Stanford Medical School in Palo Alto in 1959. His private practice had
never matured in San Francisco and the offer of a full-time salary was
something he could not afford to refuse. Bert Halter, Cohn’s backup, filled his
position for the next few years. Bert was the most respected member of
Mathewson’s attending staff and continued Cohn’s tradition.
Cohn finished a very successful career at Stanford as a respected
clinical surgeon and the clinical conscience of the medical school. When he
retired, three surgeons were required to replace him, as he functioned not only as
the busiest general surgeon at Stanford, but also as the primary pediatric and
transplant surgeon.
Leon Goldman
Leon Goldman (“the Coach”)
was chief of the UC Surgical Service
from 1945-1956, until he became UC’s
chair of Surgery. However, he
continued to serve at the County
Hospital as associate dean until 1964.
Goldman was born in San
Francisco in 1904 to parents who had
emigrated from Poland. He was raised
in Taft, California, in the San Joaquin
Valley. He attended UC Berkeley on a
football scholarship, was graduated in
1926, and attended UC Medical School
in 1930. His medical education was
followed by a straight surgical
internship at the UC University Hospital.
When Howard Naffziger became head of the Department of Surgery at
UC, he decided that he would practice neurosurgery full time. He recruited
Glenn Bell to be chief of General Surgery in 1931. Bell was trained in the
Halsted method, which emphasized fine, meticulous, bloodless dissection. Bell
appointed Goldman as his first chief resident. The second year of Goldman’s
four-year residency at UC was spent as a house officer at the County.
After completion of his chief residency at UC in 1935, Goldman was
appointed instructor and executive officer of the UC Surgical Service at the
County under Harold Brunn. Naffziger encouraged Goldman to obtain some
advanced research experience in basic science. In 1938, Naffziger helped get
Goldman a fellowship in gastrointestinal physiology with Andrew Ivy at
Northwestern University in Chicago. Goldman returned to the County in 1939 as
assistant professor of Surgery, resumed his duties as executive officer under
Harold Brunn, and was responsible for the student teaching program. In 1942,
Brunn retired and Horace McCorkle took over the position as chief of service
for two years. In 1945, Goldman was promoted to associate professor and chief
of the UC Surgical Service at the County.
40
Goldman had a distinctive hoarse, breathy voice that was a family
characteristic—his brother “Artie,” a thoracic surgeon in Los Angeles, sounded
just like him. Goldman was a big, physically impressive man, but he was
troubled with Crohn’s Disease for most of his adult life. After suffering for years
with the disease, he prevailed on Glenn Bell to operate on him. Alan Johnson—
present at the operation, in 1952, where Spencer Chester was the chief
resident—indicated that they found extensive ileal disease with mesenteric
inflammation and adenopathy. As a result, most of Goldman’s ileum was
removed, which left him with “short bowel syndrome.”
Goldman’s nickname, “the Coach,” was a term of affection applied by
his residents. According to Goldman, it came about because, when he was
recovering from his operation, he wore a golden bathrobe with a large C—for
Cal—on it that had been given to him by his brother. Someone asked him what
the C stood for, and he replied good humouredly, “Oh, that’s for Coach” —and
Coach he was, forever after.
The Coach was described as a wonderful teacher and leader. He won
the medical school’s outstanding teaching award in 1955. He had some
characteristic clinical adages, such as “the treatment for right-sided PID (pelvic
inflammatory disease) is a McBurney incision.” He also had much wisdom to
impart on gastrointestinal function. One of his favorite comments, when told
that a patient had a silent abdomen, was, “How long did you listen?” When there
was a discrepancy between the clinical and radiological diagnosis, he taught that
the clinical diagnosis was most likely the correct one. He particularly
emphasized a thorough clinical history and physical examination.
Goldman enjoyed a warm relationship with his housestaff. He would sit
with them after lunch at the County and regale them with stories about surgical
history or discuss sports, current events, or any topic of the day.
The Coach always seemed to be around during the regular workweek at
the County, despite a busy private practice at UC and Franklin Hospitals. When
his chief resident was involved in a particularly difficult operation, he would
pop into the operating room from time to time to offer clinical advice. This he
would do in dress clothes covered by an open hospital gown with a 4 x 4 held
over his mouth in deference to sterility. He rarely scrubbed with the residents at
the County, but when he did, it was always as the first assistant, not the surgeon.
He was kindly in the operating room and emphasized a meticulous,
deliberate technique. He was not a rapid surgeon, but a gentle one who never got
into trouble in the operating room. If his resident took too big a bite of tissue
with the hemostat, he said nothing, but would stop, remove the clamp and
replace it in proper fashion.
He was very thoughtful and caring of his patients. During a research
study on vitamin E injections to improve the postoperative return of peristalsis,
he asked when hospitalized that he receive the injection himself. He found that it
hurt so much that he cancelled the project. Another example of his caring
involved a long-time private patient of his who needed an additional operation
for bowel obstruction. This patient had been out of work for so long that he
could not afford hospitalization and planned to go to the County. When
Goldman heard of the plan he replied, “Nonsense,” and had the patient
hospitalized at UC and paid the bill himself.
Goldman was the primary author of more than 100 scientific articles,
many book chapters, and a textbook on carcinoma of the breast. His clinical
41
interests were the biliary tract, breast cancer, surgical endocrinology, and
calcium metabolism. In the latter endeavor, he allied with Gil Gordon, a basic
scientist, and they collaborated for many years. He developed an active clinical
practice, which in later years emphasized thyroid and parathyroid surgery.
Goldman enjoyed all sports but particularly loved Cal football. Every
year, he bought a block of tickets for either the UCLA or USC game—seats
were not available for the UC-Stanford Big Game—and took residents who
were not on call that day to the game.
Goldman was appointed chair of the Department of Surgery at UC in
1956, succeeding Howard Naffziger and Glenn Bell. However, his direct service
to the County was not finished. In 1959, after Stanford had served notice that it
was abandoning the County with its move to Palo Alto, Goldman was appointed
the first UCSF associate dean for the hospital. His initial responsibility was to
negotiate a contract spelling out a new relationship between the County and UC.
As long as there had been two Universities sharing facilities at the County, the
County administrators had played one University against the other. There were
no outpatient clinics because both Universities ran indigent clinics of their own.
Moreover, the County did not provide laboratory support—only the Universities
did. Now, with only one University involved, the County’s feet could be held to
the fire, as the County could not continue to provide services without UC’s help.
Goldman, with the help of a supporting committee, negotiated a contract that
required the County to develop a proper laboratory facility and fund the staff
necessary to run it. The contract also required the County to provide anesthesia,
pulmonary, and cardiac services. The budget negotiated for University services
was 1% of the annual hospital budget. Goldman remained associate dean until
1964 when Moses Grossman, chief of Pediatrics at the County, succeeded him.
Clayton Lyon
Clayton Lyon was born in 1905. He
was graduated from UC Berkeley in 1929
and from UC Medical School in 1933. He
entered the straight surgical internship and
residency program at UC and completed his
training in 1936. He was particularly
interested in thoracic surgery and, on the
basis of his training and clinical experience,
was certified by the American Board of
Thoracic Surgery.
On completion of his residency,
Lyon joined the volunteer faculty at the
County and was appointed Instructor of
Surgery. He also entered private practice at
Franklin Hospital. In 1938, he founded the
first blood bank in the western United States
at the County and, several years later, the Irwin Memorial Blood Bank for the
County Medical Society of San Francisco.
During World War II, he compromised his developing private practice
by spending volunteer time at the County and working at Mission Emergency.
When Leon Goldman became chief of the County’s UC Surgical Service after
the War, Lyon became his executive officer. In later life, he was handicapped by
42
Marie Strumpel cervical arthritis, which caused severe torticollis and chronic
pain.
With Goldman’s promotion to chair of the Department of Surgery at
UC in 1956, Lyon became chief of the UC Surgical Service and served until the
appointment of William Silen in 1961. Although Lyon’s primary clinical interest
was thoracic surgery, he also practiced as a general surgeon and published
definitive articles on acute cholecystitis and acute gastrointestinal hemorrhage.
Lyon was much respected for his selfless contribution to the County
surgical program and was regarded as a stern leader and taskmaster. He tended
to be cross with his residents, most likely because of his chronic pain. Although
not well liked by his residents, they respected him and considered him a good
surgeon.
Lyon seldom scrubbed with the housestaff after he became chief of
service. However, he was intensely interested in ensuring optimal care for
patients and insisted on almost superhuman standards of care, which he applied
to himself as well as to his residents. There is no question that his private
practice, his primary source of income, suffered because of his devotion to the
County.
William Silen
Silen was born in 1927 in San
Francisco and was raised there. He attended
local
schools
and
completed
his
undergraduate degree at UC Berkeley. He
was graduated from the University of
California Medical School in 1949, took the
straight surgical internship at UC, and
completed its surgical residency program in
September 1957. Ben Eiseman, professor at
the University of Colorado and chief of
Surgery at Denver General Hospital,
recruited him to the University of Colorado
faculty. In 1961 Leon Goldman brought
Silen back to UC and appointed him chief of
the UC Blue Surgical Service at the County
Hospital.
Silen then embarked on a brilliant research career, primarily in the area
of gastrointestinal physiology. As there were no animal research facilities at the
County, Silen performed all his research in the laboratories at the University of
California, San Francisco (UCSF) Hospital facilities. As was true during that
period of time, Silen’s academic salary was modest and he needed to
supplement his income from private practice. As a result, he spent relatively
little time at the County and he rarely operated with the residents. His primary
contribution was leading Grand Rounds and organizing and running the teaching
conferences on the Blue Surgical Service. He was an excellent teacher at all
levels. He supervised the third-year medical student surgical curriculum and
teaching at all the UCSF Medical School’s affiliated hospitals. His command of
the surgical literature was overwhelming.
A major contribution of his was getting a grant from the National
Institutes of Health (NIH) for an animal research facility at the County, which
43
added two floors to the new pathology building being planned by the City in
1963–1964. The building was not completed until the fall of 1966, several
months after Silen had left.
In 1966, Silen was offered the prestigious post of professor of Surgery
at Harvard and chair of Surgery at Beth Israel Hospital in Boston. Medicaid and
Medicare had been passed by Congress in November 1965, and many
believed—Silen among them—that there was no further need for county
hospitals. Silen wished his successor good luck and remarked as he left, “You
will likely have the job of closing the hospital.”
TRAINING PROGRAMS
For most of the period after World War II, all of the internships at the
County were rotating internships. During that time, all internships were separate
from the residency and functioned independently of them. The County rotating
internship consisted of balanced rotations through General Medicine and
Surgery, usually two months each. There were one-month rotations on the obgyn, pediatrics, infectious disease, and tuberculosis services, varied surgical
specialties, and the Laguna Honda Chronic Care Facility. Straight medical or
surgical internships were available only at the two University Hospitals.
During internship, the intern had to decide whether to go into general
practice or do a residency in one of the major specialties. To become a resident
in a major specialty required an additional application process. If the intern liked
what he saw in the local residency, he might apply there as his first choice.
Otherwise, he was free to apply anywhere in the United States.
Before World War II, interns and residents (housestaff)—with few
exceptions—were not married, and all housestaff were required to live in the
hospital. A few managed to get around this rule by not advertising their ties and
securing an apartment adjacent to the hospital, where they could respond to call
with the cooperation of the telephone operators. After the War, many of the
housestaff and housestaff applicants were older and married. To accommodate
these interns and residents, the hospital allowed them to live outside the hospital
when not on call. House officers were provided free meals, room and board,
uniforms and laundry, and $50–175 per month, depending on their level of
training.
Cal and Stanford surgery residents came predominately from their own
local medical school’s straight or rotating internships, but nearly one half came
from elsewhere. There might be 10 or 15 interns seeking positions in the
residency allied with their internship or an equal number of outside, wellqualified competitors. Shortly after the War, the chief resident and the two house
officer positions on each Service were expanded to one chief resident, one
senior resident, and four junior resident positions.
The residencies in both UC and Stanford were pyramidal. The Stanford
system had two separate independent residencies, one based at Stanford
University Hospital and the other based at the County. As both the UC and
Stanford surgical programs reached maturity, both residencies gradually
expanded. By the 1950s, the County’s Stanford program had four general
surgery resident positions available in each of the first three years of a five-year
program. This then tapered to one fourth-year senior resident and one fifth-year
44
chief resident. The UC portion of the program at the County contained an
equivalent number of junior and senior residents. As the UC University and
County surgical residents were combined into one training program, the total
service contained double this number of residents at each level. UC elected to
use their two senior positions at the County for two chief residents rather than
one chief and one senior, as was the case on the Stanford Service.
The pyramidal program resulted in a very competitive system and
could create morale problems when all the residents at any given level were
competing with one another. However, during that time, a trainee did not have to
complete all four or five years of residency to be eligible for Board certification.
After three years of residency he—for there were no women in either program
until the 1970’s—could qualify to take the Boards if he also had one or two
years working as a preceptor with a private surgeon. Moreover, Stanford had
several additional fourth-year chief residency positions available. One was at
French Hospital, another at San Mateo County Hospital. In each of these
instances, a resident service was available that provided the necessary additional
clinical experience for Board qualification.
The Stanford residency at the County rotated its junior residents to
Stanford for experience in its clinics and on its private service working with fulltime faculty. The Stanford University program, in turn, rotated its second-year
residents to the County for emergency experience. UC, with its one combined
program, rotated residents through their affiliated hospitals at all levels during
their training. Each of four chief residents spent six months at UC or Franklin
Hospitals and six months at the County.
A typical rotation for a Stanford resident in the County training
program would be to spend the first year at Stanford, one-half of the year in the
clinic and one-half on the private service. The second year entailed six months
of pathology and six months on the Stanford private service. The third year was
entirely at the County and consisted of two months each on Mission Emergency,
female surgery and tuberculosis, male surgery, orthopedics, urology, and
Children’s Hospital East Bay. The fourth-year senior house officer primarily
covered the female and tuberculosis wards and took one-half of the call on
Mission Emergency during his last eight months. The chief resident was in
charge of all General Surgery services but mostly spent time supervising male
surgery and Ward I—the city employees’ ward—and consulting.
From 1915-1966, housestaff provided day-to-day patient care.
Housestaff were in charge of admissions and discharges; wrote orders for
nursing care, laboratory tests, and xrays; and made the initial treatment
decisions. Their consultants cleared all major cases by phone, including
emergency procedures scheduled for the operating room. Problem cases were
usually saved for presentation at Grand Rounds. The chief resident supervised
the entire service, assisted by his senior resident. Except for the teaching day set
aside for Grand Rounds and conferences, the attending staff, for the most part,
were not in evidence but could be consulted by phone. Attending staff approved
operative schedules and helped the senior residents with major cases when
requested. Senior residents mostly supervised junior residents for operations of
intermediate or minimal magnitude.
The chief resident had the first choice of all operations but usually
confined himself to major cases. The senior resident had his pick of the
remaining cases. At the start of any academic year, the senior residents absorbed
45
most of the cases, but as they became confident and secure in their operating
skills, they passed more and more of the intermediate cases, such as simple
cholecystectomies, appendectomies, and hernias, to the junior residents. An
outstanding intern often was rewarded with a hernia operation or two and an
appendectomy near the end of his time on the service.
The major teaching day on the Stanford Service was Wednesday. For
the UC Service, it was Saturday. Grand Rounds for each service was held on the
male teaching ward. The chief resident selected the cases for the chief of
service’s review and for general discussion.
The chief’s medical student rounds followed Grand Rounds. The
residents delegated a medical student to each case. A group of six to eight
students would meet around a patient’s bed to hear the assigned medical student
give a detailed case presentation. The chief then quizzed the student on details
related to diagnosis or treatment. Woe be to the student who had failed to do a
rectal examination on the patient and the student whose presentation was
sketchy or who was not prepared to discuss the pathology. The rest of the
morning of the teaching day, and much of the afternoon, were devoted to
specific conferences and teaching sessions.
THE BLOOD BANK
The County Hospital had its own blood bank, which drew and
preserved blood for use by its patients. Irwin Memorial Blood Bank,
sponsored by the Medical Society, took over supervision of the County's Bank
after World War II. The rule was that residents who wanted to do major
elective surgery could do so only if their Service’s blood bank credits were
positive. The junior residents were encouraged to solicit all relatives and
visitors for blood donations. They would even solicit blood donations from
patients about to undergo hernia repairs or other minor surgery by saying,
“Even though major blood loss is unlikely, you never know.” The Stanford
residents were proud that they rarely had a case cancelled because of a lack of
blood credits.
San Francisco General Hospital’s blood bank was gradually closed by
Irwin Blood Bank, primarily because the requirements for blood banks were
progressively tightened. Sometime between 1972 and 1975 all blood drawing
and blood storage was transferred to the Irwin Blood Bank.
THE OPERATING ROOM
Each Service had three operating room (OR) days. UC had Monday,
Wednesday, and Friday. Stanford had Tuesday, Thursday, and Saturday. Esther
Farrington presided as OR supervisor. She maintained strict discipline among
the nurses and handled residents with a firm hand. There was no taking
advantage of her—and if a resident did manage to cross her, it became difficult
for that resident to get elective cases scheduled or done. In the evening, Ms.
Dozebaba—Dozy—was in charge. It was imperative that a case scheduled after
hours be a real emergency because, if a resident succeeded in bamboozling
Dozy once, that resident never succeeded again. Reprisals could be interminable
delays in the middle of the night when the resident was anxious to get a case into
the OR. Once a resident had Dozy’s confidence, however, Dozy was the soul of
cooperation. Residents knew they was in good standing when they were told,
46
“Doctor, anytime you have a real bad emergency, just bring the patient right up.
We’ll take care of it!”
The availability of anesthesia was constantly a problem. Anesthesia
coverage was provided through a City contract with a private anesthesiology
group who provided one anesthesiologist daily. The role of this anesthesiologist
was to supervise the nurse anesthetists, who were recruited and paid by the
County. As there were never enough nurse anesthetists, operations for such
conditions as hernias, rectal cases, and operations that did not enter a body
cavity were performed under local anesthesia.
Stanford always had more elective cases than UC, thanks to the larger
number of referrals from Stanford’s Medical School clinics. It remained a
constant challenge for both services to get their elective operations done because
there was never enough time for the large backlog of cases. As a result, there
was a great push to operate quickly. Most Stanford chief residents who had
received all of their training at the County learned to complete cases with
dispatch. This was given stimulus by Roy Cohn, who was famous for the
volume of cases he did as a military surgeon. In his private practice, Cohn
literally took minutes to do cases that took many surgeons hours to do. Victor
Richards, at Stanford—to whom most of the residents were exposed—was also
an extremely rapid surgeon. Unfortunately, there were occasionally Stanford
residents who, while attempting to emulate Roy Cohn by making one slash
through the subcutaneous tissue, would find themselves inside the bowel. This
surgical style was in contrast to the strict Halstedian School that prevailed at UC
under the stimulus of Glenn Bell, which emphasized the importance of
extremely meticulous surgery.
For the most part, elective surgery was covered by the ward attendings.
These were clinical surgeons on the teaching staff of the County who held
voluntary clinical appointments. They would cover a male or female surgical
ward for two to three months each year, making rounds one or two times a week
and assuming responsibility for all elective surgery. The chief resident was
responsible for contacting the attending and notifying him each evening of the
cases proposed for the next day. The attendings had the option of coming in on
their own for an interesting case or could delegate the entire responsibility to the
chief resident. The chief resident could request the attending’s help if the
operation was new or he did not feel comfortable doing it by himself.
The senior residents usually helped the junior residents on cases of
lesser magnitude, such as
hernias, rectal cases, or
cases involving the skin or
subcutaneous tissue. As the
chief resident on the
Stanford service usually
supervised the male ward,
most of his major cases
came from there. The senior
resident who supervised the
female and tuberculosis
wards usually took the major
cases on those wards and did
the many bronchoscopies
SURGERY EAST AMPHITHEATRE
47
requested by the tuberculosis service.
Under Esther Farrington, the OR was a model of efficiency. When the
nurses were not actually scrubbed for cases, they threaded needles, folded
laundry, cleaned and sterilized the instruments, and prepared sterile packs, even
while circulating. Everything was reusable. Nothing was disposed of.
Each operating room was wide open to the hospital corridor, and there
were no doors on individual operating rooms. The consultants would walk into
surgery in street clothes and enter the operating room proper. In deference to one
aspect of bacterial control, they might pull the lapels of their coat over their
mouths while they looked into the wound and ask the resident in charge, “How
are you getting along? Need any help?”
It was of interest that, when Surgery moved into the new Hospital in
1976—with its carefully controlled environment, positive pressure ventilation,
and all the accepted present-day sterile techniques—the infection rate, which
was always acceptable, did not change one iota.
TUBERCULOSIS SURGERY
One of the major advances in surgery after World War II was thoracic
surgery. Inflammatory disease, most notably tuberculosis (TB), was responsible
for the development of chest surgery as a separate discipline. There was no more
difficult surgery than surgery for chronic inflammatory chest disease. Two
previous chiefs of Surgery at the County, Brunn and Eloesser, had successful
careers based on their innovative thoracic surgery. Indications for surgery were
advanced cavitary disease, recurrent hemoptysis,
and persistent positive cultures despite antibiotic
therapy. Patients with positive cultures were
hospitalized for months or years, many as the
result of legal action, to prevent spreading the
disease to the general populace. There was
nothing more dramatic than massive hemoptysis,
a primary cause of death that occurred in patients
with advanced tuberculosis. Its primary
treatment was sedation and cold packs to the
chest wall. A surgical team was often mobilized
to do cut-downs in order to administer blood and
participate in the resuscitation. Emergency
surgery was out of the question in most instances
because, when the patient was rendered
unconscious for surgery, he or she would drown TB Cavitary Disease
in the blood in the tracheobronchial tree. No partial occluding endotracheal
tubes were available, although, in instances of a hemorrhage on the right side, an
endotracheal tube could be forced down the left main bronchus to isolate it for
ventilation while surgery was performed on the opposite lung.
With the introduction of antibiotics after World War II—particularly
streptomycin and paraminosalycylic acid (PAS)—it was possible to stop the
ravages of tuberculosis. PAS, administered as an oral liquid, was foul tasting.
The gardeners could never quite understand why they could never get flowers to
grow outside the windows of the tuberculosis building—until the nurses
48
administering the PAS ultimately learned to stand by to ensure that patients
actually swallowed the drug.
The development of isoniazid (INH) in the early 1950s gave physicians
three effective drugs that, when used in combination, solved the problem of
rapid drug resistance when only one or two drugs were used. Control of positive
sputum prevented systemic spread of TB or its spread to previously uninvolved
portions of the lung. However, there were some patients with advanced cavitary
disease who did not respond to antibiotic therapy. Those patients constituted a
group in which surgery combined with antibiotic coverage offered the best
prospect for cure of a stage of TB that, until this time, had been universally fatal.
Patients too sick for any consideration of operation were treated by
“medical collapse” therapy. Initially, a pneumothorax was used to try to collapse
lung cavities, and it was somewhat effective. Pneumoperitoneum, however,
proved to be a superior therapy. By elevating the diaphragm, the lung was
collapsed upward, and this tended to reduce the size of the larger apical cavities,
which facilitated healing.
For patients who were a little better risk, direct collapse therapy by
thoracoplasty was far more effective and could even be done under local
anesthesia. The operation was performed in one or two stages, depending on the
anticipated tolerance of the patient. For many patients, the removal of four and
one half upper ribs at one stage was optimal. However, a two-stage operation
was better tolerated: Initially the first two ribs and the posterior half of the third
rib were removed; an additional two or three ribs were removed one month or
six weeks later. Sometimes thoracoplasty was used in conjunction with upper
lobectomy. The thoracoplasty decreased the pleural space and lessened the risk
of complications because the remaining lung could then expand sufficiently to
ensure that it would fill the chest cavity.
Upper lobectomy was the treatment of choice if the patient was
perceived to have sufficient strength and pulmonary reserve to tolerate the more
extensive surgery. This effectively rid the patient of cavitary disease and was the
optimal treatment, particularly when only one lung contained advanced disease.
Middle lobectomy and/or superior segmentectomy of the lower lobe were
necessary occasionally, when upper portions of the lung were also being
removed.
A senior resident did all the tuberculosis bronchoscopies in the back
corridor of the operating room. One day a week was reserved on each service for
bronchoscopies. These operations were done with the patient under local
anesthesia by using a rigid bronchoscope. Usually, there were two to four
procedures performed each week at a major “cough and gag” session. However,
by mid year, the senior resident was extremely slick and could perform a
procedure in 10–15 minutes.
Although surgery, particularly thoracoplasty, had been used minimally
before World War II, the apogee of lung surgery came in the late 1940s and the
1950s, after the availability of antibiotics. Subsequently, early case finding and
the use of antibiotics resulted in fewer operations, and TB surgery phased out
gradually during the 1960s.
49
GENERAL SURGERY PROCEDURES
Gastric surgery was at peak incidence from 1945–1966. Gastrectomy
was the second most common major abdominal operation performed at the
County—the most common being open cholecystectomy. The primary
indications for gastrectomy were peptic ulcer disease and gastric cancer.
The standard operation for ulcer disease was a distal two-thirds gastric
resection. Initially the Billroth II procedure—gastrojejunostomy—was the
reconstruction of choice. It was thought to be easier and safer than the Billroth I
procedure—gastroduodenostomy. Dwight Harken, in Seattle, promoted the
Billroth I procedure as a much better operation physiologically; Mathewson
agreed and popularized the procedure in San Francisco, demonstrating the
operation at Wet Clinics before the American College of Surgeons in the mid
1950s.
In the later 1950s, truncal vagotomy in conjunction with antrectomy—
distal fifty percent gastric resection—proved itself to be associated with fewer
recurrent ulcer problems and was used for patients with the most intractable
disease. Although vagotomy and pyloroplasty had been introduced at this same
time by Weinberg in Los Angeles and was being used locally by Brizzolara at
the San Francisco Veterans Administration (VA) Hospital, it was not yet applied
at other San Francisco hospitals.
ONE RESIDENT’S OPERATIVE EXPERIENCE FROM 1954-1959
Head and neck
Thyroid
Thoracic
Thoracoplasty-tuberculosis
Lobectomy tuberculosis
Pneumonectomy tuberculosis
Pulmonary lobectomy cancer
Supraclavicular fat biopsy
Bronch/esophagoscopy
Cardiac (open resuscitation)
Breast
Benign resection
Radical mastectomy
Hernia
Inguinal, femoral, umbilical
Incisional
Laparotomy, diagnostic
Gastric
Gastrectomy ulcer
Gastrectomy cancer
Perforated ulcer
Appendectomy
Hiatal hernia
Biliary
Cholecystectomy
Cholecystectomy and common
duct exploration
Pancreas drain or resection
Bowel obstruction
Colon
Colostomy
Colectomy
A-P resection
22
15
50
19
6
6
11
8
>100
5
12
5
7
72
64
8
22
38
25
6
7
19
2
41
20
21
4
9
22
3
13
6
Anorectal
Pilonidal
Hand
Pediatric
Plastic
Orthopedic
Gynecologic
Vascular
Vein stripping
Portal decompression
Sympathectomy
Embolectomy
Carotid ligation
Aortic aneurysm
Iliofemoral bypass/enarterectomy
Femoral popliteal
Carotid endarterectomy
Neurosurgical
Burr holes/craniotomy
Laminectomy
Trauma
Gunshot wound abdomen
Gunshot wound vascular
Stab wound chest
Stab wound abdomen
Stab wound vascular
Blunt abdomen
Blunt chest
Miscellaneous
Perfuse leg melanoma
Hip disarticulation
Adrenalectomy
22
10
16
34
17
27
9
58
18
7
7
5
3
2
11
4
1
17
14
3
27
10
2
1
7
3
3
1
3
1
1
1
50
Biliary tract surgery also represented a significant portion of the
operating room schedule. Open cholecystectomy was the most common major
operation, slightly exceeding gastrectomy. Simultaneous common duct
explorations were performed in nearly one half of the cholecystectomies. This
was probably because indigent patients had a much longer history of neglected
disease, and indirect methods of assessing the common duct had not proved to
be reliable in ruling out common duct stones.
Operative cholangiography was introduced late, but was rarely used at
the County because of the difficulty of getting appropriate xray equipment for
the operating room.
Vascular surgery procedures in the 1940s and early 1950s were limited
to varicose vein surgery, portacaval shunts, embolectomy, and lumbar
sympathectomy. Direct arterial surgery began only in the late 1950s. Charles
Dubost, in France, performed the first abdominal aneurysm resection in 1951.
Although Jack Wylie at UC introduced aortic endarterectomy in the United
States in 1952, the operation had only limited application. The problem was that
there was no real satisfactory aortic prosthesis until Michael E. DeBakey
demonstrated the superiority of the Dacron graft in 1958.
The Stanford Service introduced angiography to the County in 1957.
Angiography involved placement of a #18 spinal needle into the suprarenal or
infrarenal aorta percutaneously through the back, with the patient prone on the
xray table. The needle was placed suprarenally if the patient had no femoral
pulses; otherwise, it was placed infrarenally.
The primary arterial prosthesis used in San Francisco between 1951
and 1962 was the arterial homograft. The County was not about to purchase
expensive plastic grafts that had not yet been proved effective. In 1957, Frank
Gerbode—chief of Cardiovascular Surgery at Stanford—approached the County
surgery residents with a plan to establish an artery bank at Irwin Memorial
Blood Bank. Each participant would harvest arteries from patients undergoing
autopsy at their hospitals. These arteries would be preserved by freeze-drying
and sterilized by irradiation. When surgeons needed a graft of a certain size,
they could order it from the blood bank. The senior residents at the County went
to work with enthusiasm, securing permission for the removal of arteries from a
large percentage of deceased patients—but when they had a good candidate for a
femoral bypass graft, they called the blood bank only to find that the bank had
been overdrawn. Despite their contribution of dozens of arteries, not one was
available. It seemed that the County Hospital banked the arteries and the other
hospitals, principally Stanford, withdrew them. The residents’ refusal to harvest
more grafts resulted in successful negotiations to ensure that one graft of each
size submitted would be saved for use at the County. When the homograft bank
was no longer needed, the blood bank returned a large number of freeze-dried
grafts to the County surgeons.
From 1958-1966, vascular surgery began to have a major role in
residents’ operative experience. Sheldon Levin, who had trained at Columbia,
initiated a vascular program for the UC Service at the County in 1958.
Oral and laryngeal malignancies were common afflictions of patients
at the County—most occurred in alcoholics and heavy smokers. Local excision
was associated with prompt recurrence. On the East Coast, Memorial Hospital in
New York City had shown that advanced oral cancers could be cured if the
51
excision were radical enough. For tongue, alveolar-ridge, floor-of-mouth, and
buccal malignancies, the so-called “Commando” operation resulted in a cure for
disease that had previously proved fatal. John Anlyan, a Memorial Hospitaltrained cancer surgeon, appeared on the scene in 1957 and offered his expertise
to the Stanford Service. Nearly simultaneously, Maurice Galante at UC mastered
the operation and brought it to the County’s UC service.
Thyroid surgery was one of the common major procedures done by the
senior and chief residents. Hyperthyroidism was treated surgically then,
although in the late 1950s and early 1960s, the merits of radioactive iodine were
being debated and a few patients were being treated successfully with it. The
problem was that radioactive iodine had the theoretical risk of late malignancy,
and it took several decades to prove that this was not a significant problem. Two
thirds of thyroid operations were for adenomas and malignances, but
hyperthyroidism was the ultimate challenge in the remaining one third of cases.
The introduction of propylthiauracil resulted in the control of toxicity after six
weeks or more of treatment, but this therapy left a large, very vascular thyroid
gland. Potassium iodide administered to the patient during the last week of
preparation for surgery markedly decreased the vascularity of the gland and
rendered the thyroid more easily and safely dissected.
Potassium iodide and propylthiauracil were not 100% successful by any
means, and the feared complication of a thyroid storm that had plagued the
operation in the 1920s and 1930s, was still a hazard. During a thyroid storm, a
patient would become flushed, sweaty, hypertensive, tachycardic and
hyperthermic a few hours postoperatively and run a temperatures as high as 106
degrees. If the crisis was severe and the patient did not respond to treatment,
eventually prostration, hypotension and death occurred. Sympatholytic drugs,
sodium iodide, sedatives, and cold baths helped alleviate the symptoms and save
patients.
Trauma surgery was not a major part of the emergency operating room
schedule. One resident’s total number of trauma operations in an 18-month
period in 1958 and 1959 was 27 (Table 1). If this experience were shared by the
fourth- and fifth-year Stanford residents and a similar number occurred for UC
fourth- and fifth-year residents, there would have been fewer than one hundred
operations for trauma a year in total, or approximately one and one half
operations for trauma per week. The City was not a violent place then—most
trauma occurred in the ghettos or among family members. The standard bar
fights resulted in beatings, although knifings also occurred.
Open cardiac compression was used to resuscitate sudden arrest in
medical and surgical patients, but was discontinued when closed cardiac
massage—introduced in 1960 at Johns Hopkins Hospital—was popularized
nationally. Open resuscitation was rediscovered at the County in 1970, when
exsanguinated trauma patients failed to respond to closed-chest technique.
Afterward, closed cardiac compression was used primarily for medical cardiac
arrests.
Charles Huggins introduced bilateral adrenalectomy for advanced
carcinoma of the breast—it was used a few times during this period. Jack
Connolly followed Oscar Creech’s example in New Orleans and introduced
isolation chemotherapy perfusion of a limb for melanoma both at Stanford
University Hospital and at the County.
52
Hand surgery was exclusively the responsibility of general surgery and
included repair of all complex hand lesions. General surgery also did all plastic
surgery. Pedicle grafts were the primary means used to replace major tissue
defects.
Neurosurgery was still part of general surgery, both at UC and
Stanford. The chief surgery resident did the burr holes, craniotomies, and
laminectomies.
Gynecologic surgery was a separate specialty, but surgery residents
could usually “steal” patients who had tubo-ovarian abscess and some who had
ovarian tumors. It also was common for general surgeons to trade a bowel
operation for a hysterectomy with the chief ob-gyn resident.
THE CLINICS & THE EMERGENCY ROOM
Most of the patients hospitalized at the County were referred from the
two University outpatient clinics or from the emergency room. The City and
County relied on UC and
Stanford’s free clinics to provide
outpatient care and did not
provide space or support for
proper clinics of its own. At the
County, there was only one
major clinic area for use of all
services. It was located in the
basement of Building 80. Each
Surgical Service had one-half
day a week to see patients who
needed a follow-up visit. If
Old Mission Emergency
patients needed attention any
other day, they were seen in the Ward Treatment Room. Patients needing longterm or recurrent care were referred to their respective University clinics.
Patients seen in the University clinics, who needed emergency
hospitalization if they were truly indigent, were referred to the County. Those
who could afford the cost of ward care might be admitted to the respective
University hospital if a bed was available.
A triage clerk—Pat Brown—screened patients who came to the
emergency room. Patients who qualified as a true emergency were asked to sit
on a long wooden bench to await their turn for examination and treatment.
Those with elective or semi-elective problems were referred to one of the
Universities’ outpatient clinics. Those patients brought by ambulance were
admitted directly to the male or female emergency ward.
As there were no other emergency rooms in other hospitals in San
Francisco before 1966, the County was responsible for all emergency care and
all emergency ambulance transport. Emergency care was provided throughout
San Francisco free of charge by the citywide system, which consisted of the
primary emergency room—Mission Emergency—and four other “Emergency
Hospitals” scattered throughout the City. These hospitals were Central, located
adjacent to City Hall; Harbor, located on the downtown waterfront; Park,
located on the eastern edge of Golden Gate Park; and Alemany, located in the
southwestern part of the city. They were all staffed by surgeons—graduates of
53
the County surgery residency by preference. At these hospitals, minor
emergencies were treated and first aid administered. If a patient needed
hospitalization and had private funds, a private physician was contacted and the
patient was transferred by private ambulance to a private hospital. If the
emergency was critical or the patient was indigent, the patient was transported
by City ambulance to Mission Emergency, which was attached to but
administratively separate from the City and County Hospital.
Until the end of World War II, the emergency system in San Francisco
functioned as an independent entity supervised by two surgeons, Butler and
Rhoads. In the 1920s and early 1930s, they did all the major surgery. Gradually,
they turned over most cases to the chief residents, the exception being those
cases of politically prominent patients. Rhoads died in Europe during World
War II. After the War, with the return of well-qualified surgeons with war
experience to the County staff, Butler turned over responsibility for Mission
Emergency to the Universities. He continued to administer the peripheral
emergency hospitals and ambulance system until his death in 1954. At that
point, as a money saving measure, the director of Public Health turned over
responsibility for administering the system to the chief ambulance steward.
As had been true since the County Hospital was opened in 1915, each
University’s housestaff covered the emergency room on alternate weeks. During
their respective week, all team members stayed in-house to cover the inevitable
epidemic of emergencies. The emergency room proper was staffed by two
teams, one team from each University. Each team was composed of a third-year
surgery resident, a first-year medical resident, two interns, and assorted medical
students from the service not on call that week. The junior residents from the
responsible service covered the busier night shift (5 PM to 7 AM). When it was
Stanford’s turn, its chief resident covered all seven days, 24 hours a day for the
entire week; the senior house officer was allowed to share coverage during the
last eight months of the year. When UC had two chief residents at the County,
the UC Service rotated them on alternate days during their week of coverage.
Each Service had a consultant who covered the entire week. UC rotated their
emergency attending from month to month. Roy Cohn covered all Stanford
Service emergency weeks from 1946-1959, when he moved to Palo Alto with
Stanford Medical School.
Typically, the emergency room attending was called for any patient
who required an operation or whose diagnosis was questionable. In most
instances, the chief resident was given the go-ahead to proceed on his own. The
attending would come in for difficult or life-threatening cases. When Roy Cohn
was at the County, the residents never really knew when he was coming in for
sure, but Roy had the knack of always showing up when a resident was in
trouble. When Roy arrived during the night, generally he would first proceed
quickly through the emergency room to survey all cases and assess whether the
junior residents and medical students were in place. Only then would he proceed
to the OR.
There were many patients presenting to the emergency room who did
not need emergency surgery, but who needed hospitalization. Among them were
patients with chronic infections or chronic leg ulcers with cellulitis—they were
referred to as grumous admissions or “grumes.” By agreement, grumes were
alternated between the two University services. The admitting triage officer—
54
Pat Brown—recorded noxious
admissions in a “grume book.”
There were some admissions
more grumous than others—a
degenerate alcoholic with lice,
fleas and multiple sores
constituted a serious grume.
The two services vied to
influence
Pat
Brown’s
decisions
regarding
the
distribution of grumes.
The purely elective
admissions, patients referred
from the peripheral emergency hospitals, and patients referred from various
physicians in the community were also rotated between the two services if the
patient had no previous record of admission. The rule was that the patient’s first
admission determined his or her service. Any patient returning for any type of
elective admission was admitted to the original University service; that is, the
service that first treated him or her. Emergency admissions were the exception—
they were assigned for the duration of that emergency illness to the service
covering emergencies. It was common for an interesting case, such as a large
tumor, to be declared an emergency so that it could be captured by the service in
charge for that week. In the fairly frequent situation in which a long-term
complication developed after such an emergency admission, it was not unheard
of for that patient to be discharged, transported to the emergency entrance, and
then readmitted to the original service for chronic care.
The only other hospital in the City that would regularly admit indigent
patients was the VA Hospital. The VA Hospital had an entirely separate
residency program, independent of UC’s and Stanford’s. If an elective
admission patient was found to have a history of military service, Social Service
insisted that the VA be called and asked to take the patient. The surgical resident
in the emergency room was responsible for making the call. If the resident had a
grume patient, he would try to “sell” it to the VA resident receiving the call as a
“great surgical case.” Conversely, if the patient had a condition that was
associated with desirable surgical pathology, the opposite was the case, and the
resident would describe the patient as louse infected, dirty, or otherwise
undesirable. The resident at the VA was used to the game and would try and pry
out as much information as possible before making a decision whether to accept
the patient or not. In one classic incident, shortly after the enthusiasm for
vascular surgery developed, the Mission Emergency resident “sold” a grume to
the VA, whom he described as having no pulses below the groin—presumably a
candidate for femoropopliteal bypass. What the resident did not relate was that
the patient was already a bilateral above-knee amputee. There was always great
glee when such a coup was successful!
Although there were cases of drug addiction, they were not routine and
drug-related abscesses requiring treatment were rare. The primary addicting
drug was alcohol or imbibed substitutes that included sterno, rubbing methyl
alcohol, or after-shave lotion. The primary indication for surgical admission of
the alcoholic was gastrointestinal hemorrhage from bleeding varices.
55
WARD CARE
From the time the
County Hospital was built and
dedicated in 1915 until major
remodeling was instituted in
the 1960s, the wards in the
main
hospital
were
alphabetized
rather
than
numbered.
The exceptions
were the top floors of each of
the four wings that were added
long after the original hospital
opened in 1915—these were
Surgical Ward “C”, Mathewson & Intern
numbered I through IV. Thus,
the first clinical building contained Wards A, B, C, and D, with the top floor
being ward I. In 1954, bonds were passed to remodel the hospital. As
remodeling was completed, each ward was given a number corresponding to
blocks 14, and the second number was the floor in the block; therefore, Ward C
became Ward 13 and Ward IV became Ward 45. The wards were arranged so
that each University Surgical Service had one male ward and one combined
female orthopedic/general surgery ward. There was a male orthopedic ward for
each service. Ophthalmology and ENT had a shared ward for each service. Each
University service had a male urology ward and a shared female urologygynecology ward. Neurosurgery was an integral part of General Surgery.
The controversial area, as far as the residents were concerned, was the
Municipal ward, Ward I. Municipal workers were covered by County insurance
for illness and injury, and Ward I was where they were treated. Ward I consisted
of a combined clinic and hospital ward. The senior faculty were paid to provide
surgical care, but—except for doing the operative procedures—all initial
evaluation and postoperative care was turned over to the chief residents.
A junior resident and
two interns provided the
primary care on each surgical
ward. The female ward was
always less busy than the male
ward, so its housestaff also
covered the consultations on
the tuberculosis ward.
The male and female
General Surgery wards were
presided over by a martial
chief nurse. Crossing her could
ruin a surgical career. The
attendings reminded the residents and interns that they were in plentiful supply,
but chief nurses who were willing to stand up to the rigors of County Hospital
nursing were few and far between.
The wards were wide open and had a variable number of beds. There
were no curtains to screen the beds because—although 24 beds were optimal—
when the numbers of patients admitted increased, beds were pushed closer and
56
closer together until they were separated only by a nightstand. Then, if
necessary, beds were placed longitudinally down the center of the ward—and
then, if still necessary, down the halls. The most crowded wards were the
medical wards in the winter, when patients with acute infectious illnesses, such
as the flu, filled the beds. There were instances in which one of the two elevators
was stopped at the medical ward and used temporarily as an isolation room.
Nursing coverage was minimal and the hospital was always short of
nurses. There were times when nurses could not be hired and nursing coverage
would drop until some scandal developed that resulted in an analysis of the
cause—inevitably low wages and long hours. The Board of Supervisors would
then reluctantly vote a pay raise and benefits reasonably comparable with those
of the private sector. At that time, positions would be filled—only to go into
slow decline as wages and conditions at outside hospitals rose to render the
County noncompetitive again. Therefore, the primary role of the director of
Nursing was recruitment. Each ward and division, such as the operating room,
constituted a separate nursing fiefdom and functioned, for the most part,
independent of the rest of the Nursing Service.
In addition to the chief ward nurse, who worked a 12-hour day six days
a week, there might be an additional junior nurse during the day, as well as
student nurses from one or more of the nursing schools. Also, there were one to
two orderlies per ward. However, at night, there was usually only one nurse for
several wards and patients tended to look after themselves. The large open ward
provided considerable safety because the chief nurse, with a glance down the
ward, could ascertain patients in trouble. Most postoperative or extremely ill
patients were placed closest to the nursing station, located at the entrance to the
ward. Patients would identify other patients in distress and seek help for them.
ICU’s did not exist in San Francisco prior to the late 1960’s.
A common bathroom opened off the middle of the ward into a separate
attached tower. A treatment room was located immediately next to the ward
entrance, where new admissions were worked up and where special procedures
were performed. There also were two private side rooms, each accommodating
two patients. These were usually reserved for dying patients, those who required
isolation for infections, or patients with dramatic problems such as hematemesis
from esophageal varices. There was a small kitchen where meals delivered from
the main kitchen could be warmed and where coffee was prepared. The nurses
used this small kitchen as a conference room. In addition, there was a ward
laboratory where the interns and medical students did urinalyses, blood counts,
and bacterial smears.
Until 1960, there was no clinical laboratory provided by the County.
Each University was responsible for its own special lab, and both were located
on the third floor of the emergency building. Stanford had one lab technician
who did blood sugars, blood urea nitrogens, electrolytes, and cultures during the
regular workday. The junior medical resident on call was responsible for doing
these lab tests after hours and on weekends. The UC laboratory was better
equipped, had two technicians, and had a broader range of tests and hours. The
interns were responsible for doing the blood counts, urinalyses, and bacterial
smears. However, these chores were readily passed to the medical students when
they were on service. In fact, many interns, when drawing for their schedules,
would try to ensure that the medical school was in session on the month when
they were going to be on a busy service, such as Medicine.
57
The junior surgical resident assigned to a ward, and his two rotating
interns, made rounds early in the morning and then again in the evening. The
residents on the male and female wards rotated nights off on their nonemergency week. On emergency weeks, both remained in-house. The interns
covered their own wards and did the detailed clinical histories and physicals on
the admitted patients. The junior resident provided a brief covering note for each
patient.
The headquarters of the Stanford Surgical Service was in the solarium
off of Ward C. UC’s headquarters was in the solarium off Ward F. The chiefs of
service each had a small office in the solarium, as well. Each service hired a
secretary to type its operative notes and look after students’ and residents’
schedules.
TEACHING CONFERENCES
Grand Surgical Rounds were held on the male surgical wards. Stanford
held its Grand Rounds on Wednesdays. UC had its Grand Rounds on Saturdays.
Grand Rounds for both Services was the event of the week. An xray view box
was wheeled to the front of the ward, and the area around the nursing station
was cleared. The chief resident’s job was to compile a list of three or four of the
most instructive cases for presentation. One of the junior residents was assigned
to ensure that all pertinent xrays were present and that the lab work was updated
and collated. The patient involved would have his bed wheeled to the front of
the ward, or, if from another ward, would have his or her gurney wheeled into
the middle of the group during the clinical presentation and subsequent
discussion.
It was traditional that all of
the voluntary attendings, who were
ward consultants, be present.
Letterman Army surgical staff and
their residents were inevitably present
for Stanford Rounds—Mathewson
had started the Letterman Army
residency after World Ward II and
traditionally spent Tuesdays there as
chief consultant. Of course, all
students, interns, and residents on
Surgery Grand Rounds on Ward C
each service were present, a gathering
of 30-35 people, all standing and observing proceedings as best they could.
Stanford rounds started with a detailed presentation by one of the
residents, accompanied by a review of the pertinent laboratory and xray
findings. After this, Matty—Dr. Mathewson—would conduct a filibuster
regarding the case. It usually went on far too long for the senior residents, who
usually had heard the lecture many times before and could give it verbatim
themselves. The housestaff, who had been up all night, often fell asleep while
standing, and occasionally there would be a crash as a dozing resident lost his
footing. As a result, the chief resident attempted to find something new to
present, avoiding pancreatitis and biliary obstruction—Matty’s favorite subjects.
After the chief’s presentation, Roy Cohn would be called on, but Roy never
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commented with more than a sentence or two. Then the ward consultants were
called on to comment or ask questions, but there was little argument with the
chief. The chief resident was allowed to ask questions or comment. On rare
occasions, the senior house officer would have the audacity to comment—if he
did, inevitably he would be passed a note from Cohn that said, “Shut up.”
Finally, a recommendation was given for the patient’s management, at which
point the bewildered patient would be wheeled away and the next patient
wheeled into place. After the formal presentations, which usually lasted about an
hour and a half, the group broke up and the chief would make casual rounds of
all beds and inquire about the patients' pathology. In Dr. Mathewson's case, he
would, at this point, select three or four cases for his medical student rounds that
followed. The chief spent the remainder of the day at the hospital participating
in other organized conferences, such as Tumor Board and the Morbidity and
Mortality Conference.
Tumor Board on the
Stanford Service was one of the
highlights of the week. It convened
on Wednesdays at 11 AM in the
classroom in the former nurses’
quarters.
Harry
Garland
was
Stanford's chief of Radiology, and his
major interest was xray therapy. He
had been very aggressive in pushing
his specialty, initially using standard
250-kV xray diagnostic equipment.
SFGH Conference Room
However, in 1955, he convinced an
affluent private patient to fund a cobalt unit. This machine could generate a
special form of high-energy radiation that penetrated tissues better and was the
first cobalt unit in San Francisco.
In 1957, a new surgical consultant at the County, John Anlyan, began
countering Garland’s enthusiasm for xray treatment of lesions. Anlyan had just
completed his surgical training at Memorial Cancer Hospital in New York and
was a strong advocate of radical surgical treatment. Therefore, the residents
looked forward to the weekly debate between the two, obviously favoring
radical surgery, which was the established method of cure for most of the cases
being discussed. This was a drawn battle because Garland, with his Irish charm
and wit, managed to snare a fair proportion of cases as a result of the voting by
neutral participants, including the medical oncologists—their having little to
offer in the way of a cure at that time.
Radiology Conference was another of Garland's conferences that the
residents enjoyed. This was a medical students’ teaching conference held at 10
AM. All residents usually attended because they could anticipate some kind of
fireworks, as Harry loved to bait the housestaff with tricky or obscure xrays.
They might consist of an apparent lung tumor, which—if the lateral film as well
as the anterior-posterior film were viewed—proved that the tumor was a nipple
shadow or a mass on the chest wall. Many of the senior surgical residents had
memorized all of Garland's tricks, so Harry neglected to call on them and
preferred using medical residents as his “patsies.” The conferences were
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stimulating, and Garland made many excellent teaching points that were long
remembered.
Tuberculosis Conference was held weekly on Wednesdays at noon and
was conducted by William Lister “Lefty” Rogers. Rogers had been Leo
Eloesser's junior associate until Eloesser retired. Rogers devoted himself to
thoracic surgery practice at French Hospital.
At the weekly Chest Conference, all tubercular patients who might
benefit from surgery were presented. Tuberculosis (TB) characteristically was
most extensive in apical segments of the upper lobes and superior segments of
the lower lobes. Thus, the disease lent itself to surgical excision once the acute
process was controlled by antibiotic therapy.
As the conference was held at noon, nearly everyone brought a lunch.
As part of the patient’s presentation, a cup of the patient’s sputum was passed
around for observation. Rogers would hold a sandwich in one hand and tip the
sputum cup with the other so all could observe the grayish necrotic or bloody
debris. Then the masked patient was brought in and quizzed by Lefty.
Thereafter, there would be discussion about the patient’s surgical risk, and
appropriate therapy would be decided upon.
Often, patients who had undergone surgery were presented at the TB
Conference and the surgical results discussed. Many times, a patient had
undergone a series of procedures involving both sides of the chest. Lefty would
palpate the thoracic incision and, in his raspy voice, comment, “Hey there, feel
this defect medial to the scapula. You boys didn’t close the rhomboids.”
Morbidity and Mortality Conference was regarded as an excellent
teaching conference by both Services, but it was one that the residents dreaded if
their patient had developed a preventable complication. Any oversight or
evidence of neglect in preoperative or postoperative patient care was sharply
dealt with. Reasons for wound infections were sought, and failure to properly
recognize and deal with a complication was harshly criticized. Dishonesty,
however, was the cardinal sin. Any suspicion of dishonesty led to a private
meeting in the chief’s office. Private meetings were dreaded and, once chastised,
the offending resident was most unlikely to repeat the mistake.
On the Stanford Service, following the Morbidity and Mortality
Conference, there was a resident’s presentation on some formal subject. Finally,
a review of an anatomical dissection was presented by one of the junior
residents.
Mission Emergency Rounds were held by Clayton Lyon at 7 AM on
Saturday mornings. The students were expected to have worked up all the
surgical cases, and they presented them in turn. All residents and interns on the
service were expected to be present. The cases and the residents’ care of them
were critically discussed and analyzed. Lyon was extremely knowledgeable
about all aspects of emergency care, particularly trauma—but he was so hard on
the housestaff’s oversights or perceived neglect that many patients were
transferred to other parts of the hospital before rounds.
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Pathology Conference, organized by Bill Silen, was one of the most
outstanding teaching conferences on the UC Service. Once a week, the
pathologists projected the week’s pathology on the screen. The housestaff were
asked to identify the tissue and then the pathology. The combination of Silen’s
knowledge of the literature and the pathologists’ expertise made the conference
a real delight.
SOCIAL ASPECTS
Housestaff quarters
were located in the middle of
the four towers that housed
patients’ wards, on the second
and third floors of the
Administration Building that
fronted on Potrero Avenue.
Quarters included a small
library and a billiard room.
The housestaff rooms were
SFGH Administration Building
large and accommodated two
“320 Club” Third Floor left
residents or interns. There was
a common bathroom on each floor. The two chief residents’ quarters were a
suite of rooms located on the opposite front corners of the third floor. These
rooms were popular sites for social gatherings for residents and interns during
their emergency week.
Outdoors, behind the two south towers, was a tennis court that was
used night and day. When the court was turned into a parking lot, the hospital
built a volleyball court in the yard between the Infectious Disease Building and
the nurses’ home. The court was located on the back northeast corner of the
property, where the Pathology Building is now. A telephone was provided, as
the overhead page could not be heard outside of the building.
Physicians were sought in the hospital by an overhead page used by an
astute group of telephone operators who mastered the art of locating interns and
residents. Needless to say, unusual locations, especially those out of the hospital,
dictated notification of an operator who would hold calls and cover for their
favorite residents when their chief wanted them located “right now.”
Several of the residents were successful in renting homes immediately
outside of the hospital, on 22nd Street, and could take emergency call from there.
Most residents lived in the hospital—the single housestaff all year long, and
those who were married only when they were on emergency call. Wives and
children were welcome for a free evening meal, and wives often joined their
husbands for dinner, especially on the weekends. When word got out that
something special was on the menu, such as steak, the dining room was
particularly crowded. In the early part of the month, meals could be excellent,
but if money ran short at the end of the month, meals could be abominable. Four
meals a day were served, the last one at 11 PM. There was usually a last-minute
rush for those on emergency call before the dining room closed at midnight.
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There were two dining rooms—a medium-size one in front of the
kitchen, which bordered on the main hall where the housestaff and attendings
took their meals, and a large one behind the kitchen for all other staff. All meals
were free and the attending staff made liberal use of the dining room,
particularly for breakfast and lunch.
Lunch, in particular, was a social event. Residents exchanged
information about interesting patients with the attendings. Consultations were
requested and often provided on the spot. Sports pools were conducted, and
good-natured rivalry and jesting went on regarding the success or lack of
success of the Cal and Stanford football, basketball, and baseball teams.
Usually, around Big Game time, the football rivalry maximized, and fans of
both teams played good-natured pranks on each other.
As a whole, the Stanford residents were perceived as a “looser group”
than the UC residents. One reason was that Stanford’s residency was based fulltime at the County, so the Stanford residents became comfortable with the
quirks and dogmas of their attendings. UC residents spent roughly one half as
much training time at the County and were not as fully adjusted to the system.
Interestingly, this same observation applied to the UC and Stanford medical
students taking parallel courses at the County—UC medical students were noted
for their tight sphincters, whereas Stanford students were more easygoing. This
might have been a reflection of the security or insecurity of their respective
residents.
One example of the social life of the resident staff related to a regular
event on the Stanford Service. The Stanford chief resident inherited a large
crock for making beer from his predecessor. Once or twice a year, in a nonemergency week, the Stanford housestaff would gather at the home of the chief
resident and brew a batch of beer. The ingredients were obtained from Al’s
Beverage Shop on 24th Street, a residue of prohibition where, hop-flavored malt,
corn sugar, and yeast were purchased. The production involved two teams of
workers. Some cleaned one-quart, glass soda bottles that had been saved for
weeks while others prepared the mixture. Because beer took about 10 days to
mature, the mixing session was held at the end of the non-emergency week so as
to ensure the availability of a bottling team 911 days later.
A hygrometer was used to test the specific gravity of the mix daily, and
when it had dropped to the point that suggested most of the sugar had been
converted to alcohol, an emergency bottling session was held. Ideally there was
a bit of fermentation left so that the final fermentation carbonated the brew.
Should bottling occur too soon, an explosive mixture resulted, which—
according to history—had ruined all the clothes in one resident’s closet and, in
another instance, had resulted in a smelly basement. At a suitable time, several
weeks later, the group once more convened to sample the product and
participate in what was inevitably a very lively party.
Although the interns and residents worked very hard and had very long
hours during this time, there was a tremendous esprit de corps. The long hours
bound them together as a team. The housestaff’s wives got together in selfdefense and had their own socials and kiddy exchange. Everyone was in the
same boat—all had a goal in mind and were working successfully toward it.
There were family problems and divorces, certainly, but the families who
62
survived the ordeal of training were stronger for it, and surprisingly few
marriage dissolutions occurred.
AMERICAN COLLEGE OF SURGEONS “WET CLINICS”
Every three years, the American College of Surgeons met in San
Francisco. The most popular program was the Wet Clinics put on by either
Stanford or UC, inevitably at the County. Wet Clinics were a “Roman circus”
and became extremely popular when the introduction of television permitted
operations to be filmed and transmitted to the major downtown auditorium. Each
University, in alternate years, picked the program—usually standard operations
of the greatest interest to attendees. It was a grand spectacle and showcased the
surgeons involved. In one Stanford year, Victor Richards put on a dazzling
demonstration of a radical mastectomy. This operation was performed in 30
minutes, during which his only instrument was the knife. His assistant operated
the electrocautery unit that coagulated the “bleeders” that Richards controlled
with the handle of his scalpel.
The same year, Mathewson demonstrated a Billroth I gastrectomy. The
problem was that he was so busy talking to the panel, who were observing and
commenting on the operation, that he inadvertently anastomosed the side of the
proximal stomach to the duodenum, leaving the distal stomach still attached.
The anastomosis had to be taken down and redone after amputation of the distal
stomach. Mathewson, with much aplomb, said, “This just goes to prove that you
can’t talk and operate at the same time.”
An equivalent Wet Clinics disaster occurred on a UC year, when the
chief of Cardiac Surgery offered to do a hernia for the meeting. The residents
had found a patient with a massive scrotal inguinal hernia that they thought
would make a dramatic presentation. The problem was that the senior surgeon
did not check out the case in advance. When he arrived and found the patient
already prepped and draped, he commented, “Why did you put the patient to
sleep? I wanted to demonstrate how the operation is done under local
anesthesia.” When he made the incision and opened the hernia sack, he found
that the sigmoid colon made up the posterior sack wall, a sliding hernia! To
complicate the procedure, the anesthesiologist—having been berated for putting
the patient to sleep—had allowed the patient’s anesthesia to become light and, at
that point, the patient eviscerated. The rest of the televised portion of the
operation consisted of the disheveled surgeon trying to replace the bowel in the
abdominal cavity. This delighted the audience, but humiliated the surgeon—no
doubt it was the last herniorrhaphy he ever attempted.
Because of medical-legal issues, the American College of Surgeons
was forced to discontinue the Wet Clinics in 1970.
COUNTY CHARACTERS
Tom Albers, Hospital Administrator
During the period from 19411968, one man was the administrator of
the hospital, Tom Albers. His staff consisted of only one secretary. His primary
responsibility was to control spending, stay within the hospital budget, and keep
63
a careful eye on personnel. He allowed no
vacation time for interns or residents, and if time
off was needed, his permission was necessary. If
someone in the family died—sickness and illness
didn’t count—it might be possible to convince
Albers to allow the housestaff member a day or
two off. If an intern ordered too many
antibiotics, he might have to meet with Albers to
explain why. Certainly, if a special, expensive
antibiotic was needed, the order had to be cleared
with Albers. If an intern broke a glass syringe
used for drawing blood, he had to take the shards
to Alber’s office in order to get a replacement. In essence, Albers micromanaged
everything that went on in the hospital.
Glenn Mue, Xray Technician
Patients in Mission Emergency who needed an xray examination
required transportation halfway across the hospital to the xray department,
where Glenn Mues, the xray technician, presided in the evening. As there were
no xray residents in-house at night, it was customary for the emergency room
(ER) medical and surgical residents to traipse up to the xray department and
read the films taken during the previous hour. Initially, when a new crew of
residents started in the ER, Glenn would stand behind them and let them read
the films. After the residents had committed themselves, he would step forward
and point out the obvious fracture they had missed or the spot on the chest xray
that suggested tuberculosis.
Glenn was a big man with a stiff leg that caused him to have a major
limp. In spite of this limp, he could turn out work so fast that, when he finally
retired, it took three technicians to replace him. He would lift a helpless patient
off the gurney, stand him against the chest xray plate, run across the room,
punch the button to expose the film, then run back, catch the patient as he fell,
and place him back on the gurney.
Mrs. Margaret Fogler, Night ER Supervisor
The commanding presence at Mission Emergency on the evening
shift, the busiest time of the day, was Mrs. Margaret Fogler. She had grey hair,
had a loud, husky voice like a foghorn. Her command post was the nurses’
station, where she could look out and screen all patients being admitted. She
would glance at the patients and direct her nurses and orderlies: “Better bathe
and Quell that one. Call the obstetrics resident right now—that one is nearly
bled out! Put that one back in the cell and call the psych resident. Get the
surgery resident in here right now—that one needs to go to the operating room.”
She played ER triage like a musical conductor, and her priorities were always
right on the money!
Don Longanecker, Photographer
Don Longanecker was not much more than five feet tall and always
wore a hospital gown, which reached to the floor and was open in the back. His
studio was in the rear of the xray department, where he had accumulated a
display of dramatic photographs of all sorts of amazing pathology. He was hired
64
by the Cancer Registry but was available as the institution’s photographer. He
never seemed to be doing much of anything, but when asked to take a picture, he
was always “too busy.” However, if the housestaff member pleaded with him for
a little while, he would relent and agree to take the photograph
Harry Garland
Harry Garland, the Stanford chief of Radiology, was a bright, crafty
Irishman with Gaelic charm. He never lost a debate—at least he would never
acknowledge he lost one. When he got himself backed into a corner by making
some outrageous statement, he would quote the literature to prove his point. Bill
Silen challenged him outright in one such circumstance and said, “Dr. Garland, I
looked up that so-called reference of yours and it does not exist.” To which
Garland replied, “Billy boy, Billy boy, you have been reading again.” This
turned the laughter on Silen and diverted the audience’s attention from Garland.
Garland was not averse to talking patients out of surgery. In one such
instance, when the patient was represented at Tumor Board several months later
with post-irradiation recurrence, Garland indicated that the previous
recommendation of Tumor Board had been xray therapy. The chief surgical
resident stood up and challenged him, “Dr. Garland, that just isn’t so. The
previous Tumor Board recommended surgical treatment and you talked the
patient out of it!” With that, Garland exploded and ordered the resident out of
the room. Subsequently, he demanded that the resident be fired.
Matty—Carl Mathewson—quizzed the resident, who stoutly
maintained the veracity of his statement. Fortunately, the radiology residents had
informed him that Garland had a duplicate file—the original file contained the
secretary’s notes taken at Tumor Board. With that, Matty smiled and arranged a
meeting with Garland to discuss the issue. In the middle of the meeting, after
hearing Garland out, Matty inquired, “Doesn’t your secretary have notes of the
meeting?” Not waiting for an answer, Matty picked up the phone, called the
secretary, and said, “Dr. Garland would like you to bring your notes of the June
1957 meeting of Tumor Board up to my office.” These notes confirmed that the
recommendation had been surgery. With that, Garland spluttered an abrupt
apology and left.
INCIDENTS & ANECDOTES
Sunday Rounds
The highlight of the week on the Stanford Service, or at least the most
stressful time, was Sunday rounds with Roy Cohn. Cohn's habit was to make
rounds on Ward C every Sunday at a time that was never designated, but
anywhere from 7 AM to noon. He would often bring his two young sons with
him and leave them in the Ward C solarium. They usually tore up the room,
much to the distress of the secretary who found a mess when she came to work
on Monday. The chief resident's job during rounds was to describe the
pathology on each case in a rapid tour that rarely lasted more than 15 minutes.
Roy had a knack of identifying the patient with an unsuspected complication and
inquiring for more detail. One Sunday, in the course of making rounds, the
resident—to his horror—could not identify a patient who occupied a bed that the
65
resident had previously thought was empty. In the middle of the resident’s
apology, while the group was approaching the patient for examination, the bed
seemed to explode open as a medical student burst from the bed and ran terrified
down the hall. He had been on call all night in the ER and, to avoid the
possibility of being caught asleep there, he had found an unoccupied “safe” bed
on Ward C.
How to Capture a Case
Residents were always hungry for good cases. The senior resident had a
female patient diagnosed with pancreatic cancer and had scheduled a Whipple
procedure. Dr. Mathewson and the chief resident indicated that they planned to
participate. Both were duly notified that the patient was scheduled as the first
case on Thursday. The senior resident then made arrangements with the
operating room to start the case at 5 AM. When Matty and the chief resident
arrived at 8 AM, the tumor was out. As a result, Matty felt compelled to caution
his residents, “Do not start a case until I am there.”
An Intern Does a Case
Sheldon Levin was the ER consultant one very busy night. The chief
resident was doing an emergency gastrectomy, and as it was going well—Levin
just observed. Another housestaff member tapped Levin on the arm, “Dr. Levin,
they just brought in a man with a gunshot wound of the abdomen. He is in
shock. May I bring him up?” Levin then helped the housestaff member through
a very complex case that involved the pancreas, stomach, colon, and diaphragm.
At the completion of the case, which went well, Levin inquired for further
details about the surgeon, only to find out that he was a rotating intern. The
intern had presented the case so maturely and with such presence that Levin had
assumed that he was at least a third-year resident. (…as told by Bob Albo)
Tuberculosis
The scourge of the medical students and housestaff was tuberculosis.
Every year, three or four interns and residents came down with overt disease,
and many others had their tuberculin test results switch from negative to
positive. During his chief resident year, Norm Christensen developed a
pulmonary infiltrate and was hospitalized in the infectious disease unit. After
several months he was allowed up in a wheelchair. With the assistance of his
senior resident, he made ward rounds in a wheelchair.
Food
In 1949, the hospital ran out of money in December and from that
point on the food was terrible. One doctor said, “I couldn’t eat most of it and I
lived on bread and milk.” Another remarked about one dinner, “It looks like
someone emptied the grass from the lawn mower into the pan and cooked it.”
Paint Job
One year, Mission Emergency was so dingy that two of the house
officers bought several gallons of white paint and covered everything with it,
66
including the ER gurneys. Tom Albers, the hospital administrator, was so
pleased he gave them a party and paid for the white paint.
My Name is Fred
Fred was a patient who had survived a severe head injury and would
wander about in the hospital. The nurses put a sign on him that said, “My name
is Fred. Please return me to Ward F.” The UC surgery residents disliked the
Stanford surgical secretary, so one evening they locked Fred in the Stanford
office after giving Fred a stapler and showing him how to staple all the pages
together on the Stanford Service’s charts.
Boxer Rounds
When Norm Christensen was chief resident, it was his custom to walk
his boxer dog on Sundays—this included bringing his dog with him when he
made ward rounds.
Acute Cholecystitis
The policy on the Stanford Service was, “Never do a cholecystectomy
on a patient with acute gallbladder disease. If the patient is sick enough to
warrant surgery, then the treatment should be cholecystostomy under local
anesthesia.” The patient would then be sent home for six weeks to “cool off.” At
that point, the patient could be scheduled for an elective cholecystectomy. The
UC Service had the opposite philosophy, “Always operate and remove the
diseased gallbladder. This lessens morbidity and does not increase mortality.”
What this policy accomplished was to ensure that the UC Service did
twice as many cholecystectomies as the Stanford Service. Stanford’s patients,
when sent home to recuperate, usually did not come back for their elective
surgery and returned only after having another attack. If they came back on
UC’s week, they were operated on; if they came back on Stanford’s week, their
surgery was deferred again. Only in the late 1950s, after the Service published a
paper documenting the superiority of their approach, were the Stanford residents
allowed to operate on acute gallbladder disease.
A Message from God
A psychotic man was brought in by police and, with great difficulty,
was thrust into one of the psychiatric cells. It was alleged that he had been
stabbed, but he was a big guy and so violent that no one dared to enter the cell to
examine him. In order to monitor the cells, there was a loudspeaker system. The
Mission Emergency resident at the time went to the loudspeaker, turned it up
high, and in a big booming voice said, “This is God speaking. Lie down and shut
up!” With that, the patient lay down quietly and allowed himself to be
examined.
The Good Samaritan
A man ran into the ER. He said, “I picked up a woman I found
unconscious in the street. She is in my car just outside.” The unconscious patient
was immediately transferred to the ER resuscitation room. In the excitement, the
Good Samaritan followed. As he watched the initial resuscitation attempts he
passed out, hit his head on the floor and was rendered unconscious. He was
placed on an adjoining examination table, where it was noted that one of his
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pupils was larger than the other. A few minutes later, the man awoke to find
himself naked, catheterized, and with an intravenous line running. It turned out
that one pupil was larger than the other as the result of an old eye injury.
“How about a little volleyball?”
The Stanford residents frequently had a volleyball game going in the
late afternoon when most of their chores were done. A favorite maneuver was to
go into the operating room on UC Service operating days and bounce the ball in
the doorway, challenging the UC residents to come out for a little game. This
usually fell on deaf ears!
A Little Too Much Volleyball
The Stanford residents challenged the UC residents once too often! One
year, the UC Service responded by subjecting the Stanfordites to a smashing and
thoroughly humiliating defeat. Bob Albo, the UC Chief Resident at the time,
had been a basketball and volleyball star during his undergraduate days at
Berkeley. His team of semiprofessionals cowed the Stanford residents so
thoroughly that it was a long, long time before they did any more challenging.
Cholecystectomy Race
A Stanford resident—we will call him Jack—and a UC resident—we
will call him Bud—had a bet to see who could do a cholecystectomy the fastest.
Jack won by 15 minutes and claimed 15 beers from Bud. A week later Bud
called Jack. “If you put two cases of beer in my room right now I won’t say a
word.” It seemed that the specimen Jack had submitted to pathology came back
with the diagnosis of “normal kidney!”
Neutering Business
The surgical residents were frequently approached by other members of
the hospital staff who asked them to neuter their pets. A pack of sterile
instruments and towels were borrowed from the operating room, and the
operations were performed in the main autopsy area in the pathology building.
Pentothal was the anesthesia of choice, administered intravenously in dogs and
intraperitoneally in cats.
CASES
Tracheal Stenosis
Roy Cohn was always available to help with the more difficult cases.
One such case was that of a young Hispanic American female, perhaps 18 years
of age, who was admitted with acute disseminated tuberculosis. The Surgical
Service was called to see her urgently because of acute tracheal obstruction.
The xray suggested that the location of the obstruction lay in the distal trachea,
where all but 23 mm of the tracheal lumen was occluded. Despite receiving
oxygen by mask, she remained in respiratory distress. As it appeared that the
routine tracheotomy that surgery had been asked to perform would not be
possible, Roy Cohn was called. Cohn looked at her struggling to breathe—she
had severe supraclavicular and intercostal retraction—and suggested a trial of an
oxygen-helium mixture before resorting to a desperate operation to open her
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airway. This provided dramatic relief but, of course, did not solve the problem.
Cohn then proposed tracheal replacement with a homograft trachea, which the
residents obtained from an autopsy at Stanford.
During the operation, Cohn exposed the trachea in a matter of minutes by
using a median sternotomy. He then sliced the trachea open longitudinally and
had the anesthesiologist advance the endotracheal tube into the left main
bronchus. He patched open the stenotic area with an ellipse of Ivalon (plastic).
Next he created a tracheal opening in the usual location just below the cricoid
cartilage and seated the tip of a tracheotomy tube right at the tracheal
bifurcation. The patient survived the procedure, was cured of her tuberculosis,
and was discharged about a year later.
Splenoportography
In some instances, the ability to perform a portocaval shunt in a patient
with bleeding varices was compromised by thrombosis of the portal vein. Cohn
favored working patients up by injecting contrast media percutaneously directly
into the spleen with a #18 spinal needle. This made it possible to see the splenic
and portal veins. Splenic pulp pressure could also be measured, which was a
direct reflection of portal vein pressure. Surprisingly, complications were
negligible.
Above-Knee Amputation
One UC resident scheduled a high-risk patient at Laguna Honda
Hospital for above-knee amputation under local anesthesia. The operation was
proceeding slowly when the attending arrived. He stood and watched for a few
minutes, and then said impatiently, “We need to get this thing over with.” He
quickly scrubbed and promptly clamped the isolated but still intact sciatic nerve.
The patient gave a terrible scream and fell off the table. It seemed that the
resident had not yet injected any local anesthetic into the sciatic nerve! Great
confusion ensued before the patient could be placed back on the table and the
operation completed.
Gunshot Wound of the Head
One busy Saturday night, the police brought a comatose patient with a
gunshot wound of the back of the head into the emergency room. The
emergency room was extremely busy, so—as the patient was not expected to
live—the patient’s gurney was pushed back to the cells where psychiatric
patients were kept. At 7 AM rounds the next morning, the residents walked
down to the cells to complete the paperwork on the unfortunate victim. When
the door was opened, there was the patient sitting on the edge of the gurney. He
asked, “When’s breakfast, doc?” On xray, the bullet was found flattened against
the back of his skull.
Annular Rectal Tumor
One of the junior residents excitedly called his chief resident. He had
just examined a patient with a proctoscope and observed a round, smooth,
“napkin ring” tumor at 12 cm. The chief hurriedly arrived and found the patient
on the proctoscopy table, carefully draped, with the proctoscope still in place.
There was a smooth round mass all right—the uterine cervix!
69
Stab Wound of the Heart
The ambulance brought a young boy with a stab wound of the chest to
the emergency room. The boy had no sign of life, and the ambulance driver
apologized but said they could not just leave him in front of his parents. He had
no pulse or vital signs, but Willie Schaup called Roy Cohn, telling him he was
going to take the boy to the operating room anyway. Cohn replied, “Don’t to it.
You can’t save them all, hot shot.” The anesthesiologist refused to participate,
but Schaup opened the chest, found a bulging pericardium, opened it, and
encountered a fountain of blood. His finger over the hole controlled the bleeding
from the heart that was now pumping vigorously. Cohn arrived as Schaup was
trying to place a myocardial suture to no avail. “Place a suture in the apex and
use it for traction to control the heart,” Cohn advised. With that, Schaup was
able to close the hole. The patient recovered!
Bleeding Carotid Artery
A junior resident and a senior resident received an urgent call from
Central Emergency one Sunday morning concerning a patient with a stab wound
of the neck. The nurse asked that someone come quickly because the physician
had his finger on a bleeding carotid artery and could not move the patient
without risking further hemorrhage. The residents borrowed two vascular
clamps from the operating room, subpoenaed an ambulance, and, on their
arrival, managed to get vascular control with their two clamps. They brought the
patient back to the County and successfully repaired the vessel. For this they
received criticism from their attending, their service chief, and the hospital
administrator, who felt that they should not have left the hospital. Moreover,
their attending felt that they should have ligated the vessel rather than repaired
it.
Mr. Enolaba
In 1958, two interns had
gone abalone hunting during their
weekend off. They decided, as a
prank, to send a piece of the
abalone gastrointestinal (GI) tract
to pathology labeled “rectal
biopsy.” The chief pathology
resident was an extremely sober,
conservative individual who almost
never would make even a tentative
“Mr. Enolaba”
diagnosis on his own. Although the
specimen sent to pathology consisted of a major chunk of tissue, a repeat biopsy
was requested. By this time, the whole Surgical Service was involved and the
decision was made to give the interns time off to collect another specimen.
When they returned, the xray department injected contrast media into the GI
tract of the abalone and took a film. After that, the specimen was resubmitted
and a request was made that the patient be presented at the next Tumor Board.
This resulted in the need for pathology to commit itself regarding the nature of
the tissue. Dr. Harry Garland, the chief of Radiology and chair of Tumor Board,
70
was delighted by the case. So, “Mr. Enolaba”—abalone spelled backwards—
was presented to the effect that this lesion was seen on GI series and biopsied.
The Pathology Department still refused to commit themselves and indicated that
they had sent the slides to the Armed Forces Institute of Pathology for review.
The GI series was then shown, much to the embarrassment of the pathology
staff.
Iatrogenic Arteriovenous Fistula
The Stanford Service had great fun with a case inherited from the UC
Service. As mentioned earlier, the service that was covering emergency week
treated any emergency presenting to the Emergency Department. However, if
the patient coming into the emergency room did not have an urgent problem and
had previously been admitted by the opposite service, that patient was to be
admitted to the original service. In this case, a former Stanford patient presented
to the emergency room with a chronic leg ulcer during UC’s emergency week.
No popliteal pulse could be felt, so the diagnosis of superficial femoral artery
occlusion was made. The patient then underwent an emergency femoralpopliteal bypass procedure in which a homograft artery was used. The patient's
leg appeared to be warm and well perfused; however, the ulcer was extremely
painful and continued to enlarge. The patient was nonetheless discharged from
the UC Service and was immediately readmitted to the Stanford Service as
having a chronic problem and requiring amputation. A femoral arteriogram
showed that the homograft had been anastomosed to the popliteal vein rather
than the popliteal artery. The patient’s ulcerative lesion was by now so far
advanced that above-knee amputation was required.
Carotid Artery Biopsy
Because of a chronic shortage of anesthesia staff, there was a maximum
use of local anesthesia. This sometimes resulted in a disaster or a near disaster.
In one instance, one of the junior residents was assigned the “simple operation”
of a cervical node biopsy. He apparently had established very little rapport with
the patient, who kept complaining from under the sterile drapes about the
roughness of the surgeon. The node biopsy turned out to be a biopsy of the
carotid artery. When the senior resident was urgently summoned to the scene to
assist, there was blood on the ceiling and a very pale, sweaty junior resident
holding pressure over the bleeding site. The patient under the drapes was
exclaiming, “I told you so, I told you so, you are an incompetent s.o.b.”
Fortunately for the patient, the defect in the artery was readily repaired with
simple suture. The patient absolutely refused any consideration of a repeat
attempt to biopsy the large lymph node, signed out against medical advice, and
disappeared from the surgical scene.
The Suicidal Kidnapper
One of many conflicts with the lay press involved the kidnapping of a
newborn baby of a prominent physician from a private hospital. The woman
kidnapper was admitted to Mission Emergency with slashed wrists after an
attempted suicide. News reporters invaded the women's ward in the emergency
room while the residents were trying to examine her and administer care. The
press totally disrupted all treatment of patients. When one physically
intimidating intern attempted to clear the patient-care area, the press threatened
71
to intervene with the mayor and have him fired. While the woman’s lacerations
were being repaired, they even burst into the operating room with their cameras.
After treatment, the woman was admitted to psychiatry and put in a
locked ward. She promptly removed and swallowed her bedsprings. A back
corridor was used to take her to the basement and through a tunnel to xray. As
she arrived in xray, the press descended once again and did their best to get her
xray film. Glenn Mues’s intimidating presence saved the day and kept the news
reporters at bay. The residents read the film in the dark room. As was true in this
case and many others, there were always employees of the hospital who were on
the payroll of newspapers. These employees contacted the newspapers whenever
there was some newsworthy event. As this was a public hospital, the news
media considered that they had a perfect right of access to all patients under all
circumstances. As far as they were concerned, there was no such thing as a
patient’s privacy.
Depressed Skull Fracture
An elderly man with a white beard was admitted to Mission Emergency
for treatment of two depressed skull fractures. He said he was sitting by his
television set when a man came in to rob him and hit him on the head twice with
a hammer. Thirty minutes later, another man was brought in by ambulance for
treatment of a stab wound. This patient said that he was sitting by his television
set when a robber broke in, stabbed him, and stole his television. “Anyway,” he
said, “I got him good. Hit him twice on the head with my hammer as he was
going out the door!”
Identifying an Abdominal Mass
Dr. Goldman paged a resident and told him to go to the emergency
room, as there was a patient there that he particularly wanted the resident to see.
The patient was a very elderly man and, on examining his abdomen, it was
obvious to the resident that the man had a large bottle in his left colon. The
resident called Dr. Goldman and told him his findings. Goldman's reply was,
“That is apparent, but what kind of bottle? It is obvious that you did not palpate
the name on the bottle.” When the resident replied, “No,” Goldman said, “I have
determined that it is a Pepsi Cola bottle.” Sure enough it was. When the resident
asked him about it later, Goldman's reply was, “The experience should teach you
the importance of taking a thorough history.”
The Fracture Case
Matty treated fractures all his life. He had treated the wife of a
prominent physician for a tibial fracture. Unfortunately, at the time that the cast
was to be removed, Matty was out of town. He had not been able to find anyone
to cover for him and Roy Cohn would not treat fractures. Therefore, he arranged
for the patient to come to the County to have his chief resident remove the cast.
The resident met the patient at the front door and then led her to the cast room,
having previously removed all derelicts from the room. As he proceeded to cut
the cast, the patient insisted that the cast cutter was cutting her. The resident
assured her that the cutter would not cut skin and demonstrated the saw on his
hand. However, before that cast was entirely removed, blood began welling up
and when the cast came off, the resident found that he had made a longitudinal
cut the length of the patient’s leg! It seems that Matty did not pad his casts, but
72
placed the plaster directly on the skin. The resident treated the cut as best he
could. When Matty returned, he took the complication with equanimity. He
informed his resident that he always placed a strip of cloth down the lateral
aspect of the leg to cut upon, but he had forgotten to tell this to the resident.
A Splitting Headache
The screening social worker in Mission Emergency was confronted
with a man complaining of a bad headache. Without looking up, she castigated
the man for his frivolous complaint. Then, finally—looking up at the man still
standing there—she noticed the handle of a knife sticking out from his head.
The shocked social worker immediately led the man to an examining
room. The residents encountered a rather jovial man who said he was sitting at
the bar minding his own business when he felt a sudden blow to his head.
Examination disclosed nothing more than a pocketknife handle in the side of his
head. Xrays disclosed a knife blade that passed horizontally along the floor of
the skull nearly to the midline.
Frontoparietal craniotomy was performed to remove the knife blade, as
there was fear of catastrophic hemorrhage from the circle of Willis with
extraction. However, absolutely no damage was found intracranially, and the
knife was removed without incident.
Mrs. Fogler Misses One
A large woman on a gurney was wheeled passed Mrs. Fogler in
Mission Emergency.
“Well, sweetheart, what is your problem?” she said.
“I’m bleeding,” said the patient.
“Take her to the exam room and get her up in stirrups,” said Mrs.
Fogler.
The housestaff member who was urgently summoned could see blood
all over, but he could not find the source of the bleeding with a vaginal
speculum examination. “When did you stop bleeding?” he asked.
“I’m still bleeding,” was the response. “Up here.”
The patient had two slash wounds of the chest. Fortunately, there was
no serious internal injury.
An Errant Cholecystostomy:
The Stanford Service constantly teased the UC Service about their
lengthy operations. One Stanford chief resident walked out of his emergency
cholecystostomy and bragged, “Took only ten minutes.” He said this while the
UC Service in the adjacent room was doing a lengthy cholecystectomy.
However, the Stanford patient did not do well, so a contrast study was
performed. The study indicated that the cholecystostomy tube was in the
transverse colon.
SUMMARY
After World War II, a two-tiered system of health care was still present
in the United States. County hospitals were the only source of care for the
indigent and for elderly retirees, and they were poorly funded as compared to
73
private hospitals. Almost all infectious disease, including tuberculosis, was also
the province of the county hospital.
Physically, county hospitals were large structures with large, open,
often densely crowded wards. Supplies, equipment, and, more rarely, good food
were often in short supply. County hospital nurses were overworked and
underpaid, and there were constant nursing shortages.
Advances in surgery that resulted from World War II stimulated the
need for additional surgical training. Before the War, generalists with little or no
formal surgical training did most of the operations performed in the United
States. The introduction of blood banking and antibiotics, and advances in
anesthesia and in technical surgery generated by the War, had resulted in the
potential for new, more complex surgical treatment. Although the American
Board of Surgery had been organized shortly before World War II, criteria for
surgical training were still in their infancy in 1945. During this period, county
hospitals were the optimal sites for the expansion of surgical training for two
reasons: the first was that they represented an optimal training site for more and
better surgeons; the second was that the presence of training programs served to
improve the quality of surgical care provided to indigent patients.
This was the situation at San Francisco City and County Hospital when
Leon Goldman and Carl Mathewson became chiefs of the UC and Stanford
Surgical Services in 1945. The two new chiefs of the Surgical Services
participated in upgrading and setting new standards for surgical training. Both
lobbied and obtained financial support for expansion of their respective training
programs.
The surgical schedules at the County Hospital were markedly
expanded. Surgical treatment of tuberculosis advanced rapidly as antibiotics
permitted resection and cure of the disease. Gastric, biliary, and esophageal
surgery flourished. Thyroid surgery, previously associated with high risk, was
now much safer thanks to the introduction of drugs that controlled the toxicity
and vascularity associated with hyperthyroidism. Radical cancer surgery became
practical, and cures of previously lethal head and neck cancers became possible.
Previously untreatable vascular disease also became curable surgically.
Removal of lethal aneurysms was possible because arterial replacements became
available. Amputations could be prevented by endarterectomy and arterial
bypass procedures.
The housestaff worked with minimal pay to provide this surgical care,
but despite the long hours necessary to accomplish their work, the morale of the
interns and residents was, for the most part, excellent. Even though their work
often entailed menial chores, the housestaff knew they were essential and were
providing good care to those most in need. The challenges they faced and
overcame prepared them to be accomplished surgeons and leaders in their
respective hospitals after they completed their training.
74
TRAINING PROGRAMS
University of California Chief Residents
1945–1946
John A. Morgan
William P. Pollack
Alden W. White
1946–1947
Alex Gerber
1947–1948
Ralph L Byron, Jr.
Edwin J. Wylie
1948–1949
Orville F. Grimes
Woodring Pearson
1949–1950
Philip K. Ferrier
Louis D. Nash
1950–1951
Spencer T. Chester
Dale G. Foster
1951–1952
Cooper Davis
Earl B. Fenston
Maurice Galante
Richard E. Gardner
1952–1953
Robert B. Green
Edwin E. Kerr
Jack D. Thorburn
1953–1954
Orland G. Davies
J. Malcolm Edmiston
1954–1955
Frederick M. Binkley
James A. Bulen
Robert Johansen
Allen H. Johnson
1955–1956
Quenton Bonser
George Guido
1956–1957
Donald Hine
Albert K. Mineta
William Silen
Gordon J. Sproul
1957–1958
Richard E. Alquist, Jr.
Robert H. DeReimer
Paul H. Trotta
William L. Weirich
1958–1959
Peter C. Boudoures
Chauncey D. Buster
Dean L. Maudsley
1959–1960
Mahlon C. Connett
Jack Jew
John S. Najarian
Antonio C. Oposa
Jack Q. Owsley
1960–1961
Albert D. Hall
Gilbert P. Gradinger
Dwight H. Murray, Jr.
J. Burdette Nelson, Jr.
Charles P. Semonsen
Peter Teel
1961–1962
Mervyn F. Burke
Alfred A. deLorimier
J. Harold Hanson
F. William Heer
John L. Myers
John W. Smith
75
1962–1963
Abdul Al-Shamma
H. Duane Collier
William E. Dozier
Rolland C. Lowe
Paul Negulescu
Robert S. Seipel
R. Rolla Spotts
Arthur N. Thomas
1964–1965
Donald Adams
Robert J. Albo
Donald P. Elliott
Bernard Gardner
William P. Graham, III
Sanford A. Hepps
Robert C. Lim, Jr.
Herbert S. Mooney, Jr.
Ronald J. Stoney
1963–1964
Richard L. Dakin
Michael F. Hein
C. David Jensen
Dee J. McGonigle
Parker M. Powell, Jr.
John J. Skillman
Louis C. Zanger
Harry Zehner
1965–1966
John N. Baldwin
Robert B. Karp
Paul Kelly
Donald L. Morton
Lloyd W. Rudy, Jr.
William von Ruden
Stanford Chief Residents
1945–1946
Kenneth Allen
1945–1946
Phillip Westdahl
1946–1947
Peter Joseph
1947–1948
Paul Lauer
1948–1949
Burton Adams
1949–1950
Robert Quillinan
1950–1951
James Yee
1951–1952
Richard Compton
1952–1953
George Magladry
1953–1954
Cooper Davis
1954–1955
Norman Christensen
1955–1956
Richard Gross
1956–1957
Myron Close
1957–1958
Willis Schaupp
1958
William Blaisdell
(6 months)
76
1959
Paul Carlson
(6 months)
1959–1960
Dick Hibner
(Last Stanford chief)
1960–1961
Burdette Nelson
1961–1962
John Smith
(Last Stanford trainee)
SFGH HOSPITAL COMPOSITION
A Med Records
B Stanford Orthopedics
C Stanford Surgery
D UC-Stanford Urology
I City employees
I Library
J UC Surgery, Orthopedics
K UC Eye-ENT
L Stanford Eye-ENT
III Stanford Surgery, Orthopedics
E
F
G
H
II
W UC Gynecology, Urology
N UC Medicine
O Stanford Medicine
P Stanford Gynecology, Urology
IV Stanford Pediatrics
UC Medicine
UC Surgery
Stanford Medicine
UC Orthopedics
UC Pediatrics
Building 70 Tuberculosis
Building 80 Psychiatry
Building 90 Obstetrics (follow-up clinic in the basement)
Isolation Building, Infectious Disease
Pathology and the Morgue, 22nd Street building
Mission Emergency, first floor of the annex on 22nd Street
Operating room, second floor, emergency room annex
Amphitheater, third floor, emergency annex
Laboratories, UC and Stanford, fourth floor, emergency room annex
Physical therapy in the basement, emergency room annex
Radiology, second floor, kitchen annex
Dining room, staff & physicians, first floor, kitchen annex,
Administration Building: housestaff quarters, second and third floors.
77
CHAPTER III
THE BLAISDELL YEARS: 1966–1978
The changes in the County Hospital, now officially called San
Francisco General Hospital (SFGH), during this period were far greater than at
any time in its history. The Medicare-Medicaid bill was passed in November
1965 as part of President Johnson’s Great Society. The bill was passed even
though the medical profession had fought it tooth and nail and had indicated that
it represented the beginnings of National Socialism.
Medicare provided universal coverage for all citizens over age 65
years, and Medicaid supported state-funded medical assistance programs for the
medically indigent. Some organizations for chronic diseases, such as end-stage
renal disease, lobbied for inclusion, and renal disease was the first added to an
“old age” insurance plan. Eventually, transplantation, a logical extension of the
treatment of end-stage renal disease and other organ transplant procedures,
would be added to Medicare.
Medicare became one of the transforming legislative actions that
contributed to the incredible growth in influence of the academic health center.
As part of the Medicare law, Indirect Medical Education (IME) was formed to
provide a Medicare-based supplement to hospitals with Medicare patients and
teaching programs. As a 13.5% supplement to the Medicare reimbursement
when first initiated, it provided a financial subsidy to teaching hospitals that
greatly enhanced their financial bottom line. Similarly, the Direct Medical
Education (DME) stipend provided a salary for house officers and additional
funds for teaching hospitals.
The second great post World War II development was the explosion of
funding from the National Institutes of Health (NIH) during the 1960s and
1970s. The vision of Mary Lasker, Vannevar Bush, Michael DeBakey, and
others stimulated the development of a disease-based institute system with
extramural funding provided for academic health centers. This system was
designed to ensure that the United States would continue to be a unique and
dominant force in creating health research breakthroughs.
The decade of the 1960s also saw, as the result of the Vietnam War, the
“hippie generation” of young people and their loss of respect for the society of
their elders. They eschewed alcohol in favor of the drug culture. The drug
culture resulted in an epidemic of crime and violence in American cities of a
magnitude never seen before. Author Peter Drucker called this period of the last
quarter of the twentieth century one of epochal society transformation.
During this period and incidental to it, the University of California
(UC) Medical School was undergoing major transformation. During most of its
history, the school had been primarily inbred, but under the initial leadership of
an enlightened Dean, William Rhinehart, the faculty was being transformed. It
started with the recruitment of Julius Comroe in Physiology from Pennsylvania
78
Medical School in 1960, and then Stuart Cullen in Anesthesia from Iowa in
1962, J. Englebert Dunphy in Surgery from Oregon in 1964, and Holly Smith in
Medicine from Harvard in 1965. Under the leadership of these men, the Medical
School turned from its emphasis on clinical care to an emphasis on research. All
new faculty were recruited on a full-time salary system, which meant that
clinical care dollars went into the coffers of the respective departments rather
than into the pockets of the provider.
The future of SFGH was unclear. Indigent health care, by State law,
was the responsibility of the county. During the early part of the twentieth
century, that responsibility was interpreted to mean a county-supported hospital.
With the introduction of Medicare and Medicaid, the federal government
assumed financial liability for most indigent care. Now there was to be only one
standard of health care, as theoretically federal funds would now pay for private
health care for the poor. As a result, most small county hospitals closed. The
issue for the public and the lawmakers was what to do with the large municipal
county hospitals. Should they, and could they, be closed?
In April 1966, William Silen, chief of the Blue Surgical Service at
SFGH, accepted a professorial position at Harvard—an outstanding career
move. This left the position available for someone who might grasp the
challenge and opportunity. J. Englebert—Bert—Dunphy, chair of Surgery at
UC, hoped this was so when he appointed William Blaisdell as the successor to
Silen. As he was leaving, Silen commented to Blaisdell, “Good luck. I hope you
have fun closing the hospital.”
Blaisdell was confronted by the challenge of preserving the hospital
and its teaching services as he assumed responsibility for the Blue Surgical
Service at SFGH in July 1966. Dr. Carl Mathewson, Blaisdell’s former chief,
was in charge of the former Stanford Surgical Service—the Gold Surgical
Service.
THE PROFESSORS
Carleton Mathewson, Jr.
In 1966, Mathewson—chief of the Gold Surgical Service—was nearing
the obligatory retirement age of 65 years (see Mathewson’s biography in
Chapter II). Blaisdell was his protégé, and he welcomed his pupil to co-chiefship. Mathewson indicated that he did
not wish to deal with the changes in the
hospital that were being required and
suggested that Blaisdell take the
leadership in implementing the
necessary reorganization. Mathewson
retired in June 1968, leaving Blaisdell
in charge of the consolidated program.
F. William Blaisdell
Bill Blaisdell was born to
medicine. One of his grandfathers
taught Bacteriology at the University of
Keokuk (later Iowa), and the other was
a professor of Surgery (anatomy) at
79
Stanford. His father and uncle, graduates of Stanford, were a practicing internist
and surgeon, respectively, in Watsonville, California, where Blaisdell was
raised.
Blaisdell received his B.S. and M.D. degrees at Stanford. He took his
internship at Philadelphia General Hospital, and then spent two years as a
Destroyer Division Medical Officer in the Navy during the Korean War. Upon
completing his Service requirement in 1954, he returned to Stanford for his
surgical residency, which included one year at Harvard with Francis Moore.
After finishing the surgery residency at Stanford in 1959, he did a
cardiovascular fellowship under Michael DeBakey and Denton Cooley in
Houston. He had hoped to return to a position at the Stanford Medical School,
which had just moved from San Francisco to the Stanford campus, but none
materialized. While he was investigating a job offer in the Surgery Department
at the University of Oregon, then under Bert Dunphy, he was informed that the
position of chief of Surgery at San Francisco Veteran's Administration (VA)
Hospital had just become available.
Dr. Carleton Mathewson, Blaisdell’s mentor from his Stanford
residency days, informed the chair of Surgery at UC San Francisco (UCSF), Dr.
Leon Goldman, that Blaisdell was about to be appointed to a similar job in
Oregon. Partly as the result of this, and after a favorable interview, Goldman
offered Blaisdell the position at the San Francisco VA Hospital, which he
immediately accepted.
At that time, in July 1960, the VA residency was a separate,
independent program with a loose affiliation with UC’s program. A number of
outstanding individuals came through Blaisdell’s surgery residency program in
the four years that it remained independent. These included Frank Stuart, later
professor and head of Transplantation at Northwestern, Wesley Moore, later
professor and chief of Vascular Surgery at UC Los Angeles (UCLA), John Lilly,
later professor and chief of Pediatric Surgery at the University of Colorado, and
Robert C. Lim, Jr., later professor at UCSF.
When Dunphy succeeded Goldman as chair of Surgery at UCSF in
1964, one of his goals was to consolidate the surgical residency at UCSF,
SFGH, and the VA into a single high-quality program. Blaisdell had met
Dunphy during his residency rotation at the Peter Bent Brigham Hospital and
while he was being recruited to Oregon. He was enthusiastic about Dunphy’s
plan and, during the 1964-65 academic year, the VA residency was merged with
that of UCSF.
In December 1965, while Dunphy was on an extended professional
visit to Australia, Blaisdell was involved in a problem at the VA that resulted in
his leaving the institution. He and the chief of Medicine, Mervin Goldman,
found that research funds were being misappropriated by the hospital
administrators and solicited Dean William Reinhardt’s help in obtaining a VA
Central Office review.
Unbeknownst to the Dean, the UCSF Chancellor was recruited by the
VA administrators to fend off the investigation. The end result was that Blaisdell
and Goldman resigned. This discord was followed by a political confrontation
between the Dean and the Chancellor. The old guard at UCSF had allied
themselves with Chancellor John B. De C. M. Saunders, and the new senior
faculty allied themselves with Dean Reinhardt, supporting Reinhardt’s effort to
change the tenor of the school. The impasse resulted in the Dean and Chancellor
80
both resigning, but with the new guard firmly in control of the future of the
medical school. When Dunphy returned from Australia, he found that he had
been appointed acting Chancellor and Stuart Cullen, the new Dean. Dunphy's
comment was, “Bill, what have you done?”
Fortunately, a few months later, the position at SFGH became
available. For Blaisdell, it was like coming home again, as most of his Stanford
Residency had been at SFGH. However, one of the conditions that Dunphy set
was that Blaisdell must give up heart surgery, as the University’s cardiac
program was dependent on the cases from SFGH.
Blaisdell had been active in cardiovascular surgery at the VA, having
developed the VA’s first funded Cardiac Surgery Center. So his initial attention
at SFGH was directed toward developing vascular surgery. He brought with him
his NIH-supported cerebrovascular grant, which also supported his vascular
fellowship. However, during the next few years, thanks to Medicare coverage,
the older patients were gradually phasing out and the average age of SFGH
patients was dropping dramatically.
In parallel, at this same time, increasing violence in San Francisco
caused an increase in injuries, which tripled from the year 1966-1967 to 1968.
Because of the dawn of the drug culture, the City had become a violent place
almost overnight. This resulted in the need to reorganize the Service in a new
direction—Trauma.
SURGERY STAFF
Thomas K. Hunt
Tom Hunt, a graduate of Harvard
Medical School and the University of
Oregon surgical residency, was the first
recruit of Bert Dunphy, the new chair of the
UC Department of Surgery in 1964. Hunt
was just finishing his chief residency at
Oregon when Dunphy moved to UCSF.
Hunt had worked in Dunphy’s woundhealing laboratory during his residency and
planned
to
continue
independent
investigations on his own in San Francisco.
Hunt’s initial clinical assignment
was as assistant chief of the SFGH Gold
Service under Carl Mathewson. With Bill Silen—at that time, chief of the Blue
Service—there was now a full-time UC faculty member for each of the two
services. However, Dunphy was also counting on Hunt to assist in running his
new wound-healing laboratory at UC.
When Blaisdell arrived in 1966, Hunt and his research fellow, Bengt
Zederfeldt—later professor of Surgery at University of Uppsala, Sweden—were
in the process of developing an independent wound-healing laboratory at SFGH.
Ultimately, this plan did not work out, as Dunphy needed Hunt at UC to look
after his grant as well as the Department’s research fellows. Surgery residents
were now being encouraged to spend a year in the research laboratory, a change
in the residency. Also, research fellows, such as Bruce Conolly from Australia,
81
were coming to work in Dunphy’s lab and needed the supervision that Dunphy
could not provide.
In addition to his SFGH ward responsibilities, which included
emergency call, Hunt had taken over the leadership of the surgical internship at
SFGH. In the absence of any interest by the Department of Medicine in
developing an outpatient program, Hunt had also assumed responsibility for that
leadership role.
When Silen left SFGH, Edward G. Biglieri, chief of SFGH’s Clinical
Study Center and an expert in endocrine disease, began referring adrenal tumors
to Hunt. Ed Biglieri’s hypertension research included the development of a test
for adrenal hyperaldosteronism. This resulted in his finding a large number of
patients with adrenal tumors who required surgery. A little later, Glenn Bell, the
former chair of UC’s Department of Surgery, gave up his clinical practice and
turned over his UC breast tumor practice to Hunt. At this point, Hunt was being
pulled in multiple directions, and—when Donald Trunkey, who had been chief
resident at SFGH from 1970-1971, came back from a fellowship to join the
faculty at SFGH in 1972—he finally decided that it was time to move
completely to UC.
Hunt, in addition to an active clinical practice, developed a brilliant
research career in wound healing. In the course of his career, he trained dozens
of research fellows, who then returned to their respective medical schools and
became leaders in academic surgery.
Robert C. Lim, Jr.
Blaisdell considered Bob Lim the
best clinical surgeon he ever trained, and
Bob was his first faculty recruit at SFGH.
Lim was born and raised in San
Francisco. He was educated in San
Francisco Schools and then at UC Berkeley,
where he was graduated in Zoology in 1956.
He received his M.D. from UCSF in 1960.
He then took his surgical internship at UC
and his residency in Blaisdell’s independent
VA surgical program.
When Lim completed his general
surgery training, he stayed on at the VA for one year in a vascular fellowship.
He could not join the SFGH staff immediately, as Blaisdell had arranged for him
to take a research fellowship with Lars-Eric Gelin and Sven-Eric Bergentz in
Gothenburg, Sweden. It was two years before Lim was able to join the staff at
the County—July 1968.
By the time Lim returned from Sweden, the Surgery Department had
assumed administrative responsibility for Mission Emergency, and Lim was
appointed director. He handled the challenge well. Everyone he came in contact
with loved him, and in his own gentle way, he dealt effectively with multiple
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inter-services emergency room conflicts. Lim had always been a good teacher,
especially with residents, where he had the opportunity to pass on his clinical
and technical skills.
Lim established his laboratory on the northeast corner of the fourth
floor above Mission Emergency. He had returned from Sweden with an interest
in platelet physiology, and this continued to be the main theme of his research.
During his residency at the VA, he had developed the regional shock model that
bears his name. He continued to use this shock model to help clarify the etiology
of respiratory distress syndrome.
Lim’s clinical research included calling attention to the increased risk
of infection following splenectomy, which was controversial at the time. One of
his most outstanding clinical publications was that describing three ex-vivo
kidney vascular repairs, the first published in the English literature. His clinical
interest in liver trauma resulted in expertise in liver resection, and he later
developed an outstanding practice treating liver tumors. His was the most
extensive experience with the treatment of hepatoma in Northern California.
During Blaisdell’s tenure, Lim was the mainstay of the clinical
program. His surgical skills contributed in a major way to the reputation of the
elective, emergency, and trauma surgery being performed at SFGH. The
nephrologists recognized his vascular talent, and he was the only one to whom
they referred their vascular access procedures. In reward for this service, they
supported his research program through an independent contract.
Lim stayed on the SFGH staff during Donald Trunkey’s tenure as chief
and then, in 1991, he was recruited to the UC Hospitals, where he confined his
practice primarily to liver surgery. He rose to professor, not only at the medical
school but also in the School of Dentistry, where he was appointed professor of
Oral Biology. He was recognized as the outstanding member of his medical
class of 1960 and has been a member of more than 25 professional associations,
including Alpha Omega Alpha (AOA). He served as Secretary and then
President of the San Francisco Surgical Association and the Pacific Coast
Surgical Association. He has been President of the Naffziger Surgical Society
and the Alumni Faculty Association. He has been Governor of the American
College of Surgeons and President of its Northern California Chapter. He was
Vice President of the American Association
for the Surgery of Trauma. He has served on
national, regional, and UCSF committees
too numerous to mention. He has well over
100 publications in books and peer-reviewed
journals.
Muriel Steele
Muriel Steele was recruited as a
volunteer clinical attending surgeon shortly
after Blaisdell arrived at SFGH. She was
appointed to the full time staff in January
1969. For a long time, Muriel was the
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unsung heroine of the Department.
When the clinics were opened in January 1968, Steele was hired to run
the surgical clinic on the City salary that was available. Then, in the two-year
hiatus before an outpatient chief was recruited, she was in charge of developing
the entire Outpatient Department at SFGH . After Donald Fink was recruited as
chief of Outpatient Services in 1972, he asked her to continue being
administratively responsible for the medical and surgical clinics under the title,
director of the Adult Health Center. These clinics were initially conducted in the
former nurses' home that faced 23rd Street. In 1976, these clinics were moved to
the clinics wing of the new hospital.
Muriel Steele was born and raised in the Santa Barbara area of
California and initially planned on becoming a veterinarian. However, during
college she decided on a medical career. She was graduated AOA from Stanford
Medical School in 1956. She took her internship and initial years of residency at
Stanford, as well. During her junior residency, while Stanford Medical School
was still in San Francisco, she was in line to be chief resident. At that time, the
residency consisted of a pyramid that went from six to the one who emerged as
chief resident. The one selected to be chief resident was virtually always sent
elsewhere for a special year of training. The committee running the Department
elected to send Steele to St. Thomas Hospital in England during the academic
year 1959-1960. Meanwhile, the Stanford Medical School moved from San
Francisco and started anew in Palo Alto on July 1, 1959. The new chair would
not accept a woman in his Stanford program, so Victor Richards, the former
chair at Stanford, arranged for her to finish her residency in his newly
established surgery training program in the Children’s-Presbyterian Hospitals
consortium in San Francisco.
After completion of her training in July 1962, Steele’s practice was
slow to develop. She was barely making a living covering her former professor’s
patients and running the Surgical Outpatient Department at Presbyterian
Hospital. However, that latter experience served her well when it came time to
organize the SFGH clinics.
Steele suffered in comparison with the rest of the surgical staff only in
that she was a very sound but not a dynamic teacher, and she was surrounded by
nothing but dynamic teachers. She was a good, solid clinician with a special
interest in colorectal surgery that had developed during her year in England. She
was not involved in laboratory research, as her administrative responsibilities
occupied all her available time outside of teaching and clinical care. However,
during her tenure at SFGH, she produced at least one or two clinical papers a
year.
Steele organized a colorectal clinic and, in 1977, she made the
observation that there were unusual infections in the gay men in her clinic.
However, at that time she could not get anyone in the Department of Medicine
interested in studying these problems.
Steele was Blaisdell’s primary backup and functioned as the assistant
chief of Surgery. She could be counted on to chide members of the staff who
might be slighting their clinical responsibilities, including the chief himself. She
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also set up and personally supervised the Department’s billing machinery. This
included checking all outgoing bills and ensuring their collection. Steele picked
up every loose item in the Department, was the conscience of the Department,
and outworked everyone.
Women had a difficult time being recognized by Surgery during this
period of time and, in this regard, it is appropriate to point out the impact this
had on her. In 1970, it was time to recommend her for membership in the San
Francisco Surgical Society—the regional surgical organization composed of
leading clinical surgeons. Steele’s training, appointment, and publications
clearly put her ahead of most of the other applicants, but initially it was not
possible to get her accepted into the organization. One of the reasons was that,
throughout its entire history, the Society had met in a prominent men’s club—
the Family Club. The Club absolutely refused to allow women into the facility.
Ultimately, in 1972, her supporters—including all her former professors—were
raising so much protest that the organization had no choice but to admit her. As
a result, the Society was forced to move to the downstairs meeting room of the
Olympic Club, which allowed women in that area.
Membership in the Pacific Coast Surgical Society came next. By that
time, around 1974, Steele was clearly well qualified for membership. The San
Francisco caucus of the organization voted overwhelmingly in her favor. Their
recommendations were bypassed for two years straight, but finally so much
controversy was raised over discrimination against women that the organization
had no choice but to accept her. Thus, she was the first woman to become a
member of the San Francisco Surgical and Pacific Coast Surgical Societies.
Steele had the longest tenure of any chair of the Hospital Executive
Billing Committee, having served as chair in 1970, 1971, 1974 and 1975. She
served two consecutive terms as chief of the Medical Staff—1977-1979. She
died of an extremely aggressive uterine sarcoma in 1980, still working until
nearly her last hour. After her death, the Surgery Clinic in the new SFGH
buildings was named after her.
Muriel Steele was an absolutely outstanding woman. Blaisdell
considered her the most valuable member of an extremely valuable staff. “She
was the best of us all!”
Arthur Thomas
Art Thomas was born and raised in
Salinas, California. He went to college at
Seventh Day Adventist in Helena and his
medical school was the University of British
Columbia, where he was graduated in 1957.
Thomas’s internship was at SFGH,
from which he was accepted into the
Stanford surgical residency program. When
the Stanford Medical School was about to
move to Palo Alto, Thomas was the first in
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the Stanford surgical program to opt for the UC residency—a year before
everyone else. He spent his first year in breast cancer research with Dr. Leon
Goldman, the Department of Surgery chair, and Gill Gordon, an internist with a
special interest in calcium metabolism.
When he finished his residency in 1961, Thomas opted for a thoracic
fellowship at the VA under Blaisdell. This was jointly sponsored with Julius
Comroe, the director of UC’s Cardiovascular Research Institute (CVRI). At that
time, there was great interest in hyperbaric oxygen, both for circulatory arrest
for cardiac surgery and for the treatment of anaerobic infections. Thomas was
recruited to supervise the VA’s hyperbaric oxygen project, which had been
initiated by Al Hall, the VA assistant chief of Surgery. Thomas embarked on the
project with enthusiasm initially, but this keenness was tempered by his
subsequent findings. While everyone else was waxing enthusiastic, Thomas saw
its limitations, which were many. Nonetheless, when Thomas left the VA for
SFGH in 1971, he brought a portable unit with him, so there was briefly a
hyperbaric chamber at SFGH.
By 1970, John Murray, the chief of Pulmonary and Tuberculosis
Medicine, was agitating for a full-time thoracic surgeon because Blaisdell’s
primary attention was being directed toward the Trauma Program. Almost all of
the academic thoracic surgeons in that period were interested in cardiac
surgery—not pulmonary surgery. Thomas was an exception, and the solution for
Pulmonary Medicine’s needs. He was recruited to SFGH from the VA in 1971.
In his own quiet way, he brought this critical specialty the support it needed.
However, tuberculosis surgery was phasing out in favor of cancer surgery, and
Thomas’s work evolved along those lines.
One of Thomas’s major clinical contributions was to demonstrate that
air embolism was a significant factor in morbidity and mortality following lung
laceration, and he developed an animal model that proved this. He recognized
the importance of chest wall stabilization following flail chest and developed a
technique for stabilization by using orthopedic plates. He pioneered in the
treatment of hiatus hernia and the operative treatment of cardiac arrhythmias.
An important contribution Thomas made to his specialty was to
organize the Samson Thoracic Surgical Society, later called the Western
Thoracic Society. This was a major accomplishment that has been recognized by
the Society in making him a permanent member of the Society Council. As the
initial secretary of the proposed society, he organized the initial and subsequent
meetings of the Society. It was all done out of his SFGH office with his
secretary’s and Department support. This was done at a time when all the SFGH
staff were on modest salaries, and most clinical thoracic surgeons had six- and
seven-figure incomes. Nonetheless, SFGH Surgery funded the secretarial
services for the Society and paid for the numerous mailings. Although Blaisdell
lightly protested the use of Department resources without appropriate
remuneration, it was allowed to go on, even though it took much of Thomas’s
spare time for years. It was a major contribution to Thoracic Surgery and to Art
Thomas’s prestige, especially when he was recognized by the presidency of the
organization.
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Thomas’s successful outside investments rendered him relatively
immune from financial salary issues within the Department. His generous
parties, which included his residents, were an important contribution to morale.
He acquired a large block of San Francisco 49ers tickets, and regularly took
residents to the football games as his guests. His relationships with his residents
were close. He was patient with them in the operating room as he introduced
them to the intricacies of thoracic surgery. He consistently received the
Department’s outstanding teaching award and his residents affectionately
referred to him as “Uncle Art.”
George Sheldon
George Sheldon has gone further
and accomplished more than any other
faculty member or trainee in the UC
system, past or present. He “has it all,”
and in a nice, quiet, non-flamboyant way
that is impressive.
Sheldon was born and raised in
Salina, Kansas. His father, also a surgeon,
died in his fifties, while George was in
high school. Sheldon was graduated from
the University of Kansas in 1957, where
he was also student body president. He
completed his M.D. there in 1961,
followed by an internship at Kansas as
well.
In the summer of 1961, the Berlin Wall was built. Mobilization for
possible war began, and all young doctors were called up for physicals. Those
with only an internship education were drafted for outpatient assignments and
other undesirable assignments. Accordingly, Sheldon volunteered, and so he was
able to obtain an appointment in the Public Health Service and was assigned to a
hospital in Galveston, Texas.
Following two years in the service, he applied for a residency in J.
Englebert Dunphy's Department of Surgery at the University of Oregon. Dunphy
had just decided to take the chair of Surgery at UCSF and accepted only Oregon
students into the residency that year. Accordingly, because his options were
limited, Sheldon took a year of Internal Medicine at the Mayo Clinic. This,
combined with his internship and the two years of service time, provided Board
eligibility in that specialty.
That fall, Miss Chick, Dunphy’s long-time assistant who had moved to
UCSF with him from Oregon, remembered Sheldon’s application and called
offering him a residency at UCSF starting in July 1965. As the program was still
pyramidal at the time, with some ten or twelve junior residents vying for the six
senior positions, Dunphy was not really taking any chances. Moreover, he had
been impressed by Sheldon’s interest in surgical history, as Sheldon had already
published an article on Philip Sang Physick and another on the history of
medicine in Kansas.
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Sheldon had political astuteness in the best possible way, and that was
his strong card. Even from his junior residency, he had the knack of organizing
everyone around him, whether junior or senior to himself. While chief resident,
he initiated open chest resuscitation for the victims of trauma who presented
with cardiac arrest. Although the Outstanding Resident award usually went to a
chief resident, Sheldon won it in his senior year and created political
controversy in so doing. Needless to say, his potential was obvious, and before
he finished his training in June of 1959, Blaisdell offered him a position at
SFGH.
Sheldon had not spent any time in the lab during his residency. He was
encouraged by Blaisdell to spend two years at Harvard working with Dr. Francis
Moore after completing his chief residency. This proposal was received with
lukewarm enthusiasm by Dunphy, who had lost out to Moore in the competition
for the chief of Surgery at Brigham.
Sheldon came back to SFGH from his fellowship in Boston in July
1971. He brought with him special skills in surgical metabolism and nutrition.
Intravenous nutrition was just starting to be used and Sheldon was one of the
first in the field. This technique provided the ability to salvage patients critically
ill on long-term artificial ventilation and those with gastrointestinal
complications. Dr. Leon Goldman, who was dying of cancer superimposed on
chronic bowel disease, was among his first patients. In the course of his clinical
work, Sheldon developed a rat nutrition model, which he used to test his
theories.
Sheldon had a lot to do with the organization of the Trauma Service,
and he functioned as administrative officer for the Trauma Program Project
Grant. He and Muriel Steele were Blaisdell’s principal administrative deputies.
Both took initiative well and, whenever they saw or anticipated problems,
jumped in and fixed them. Sheldon’s administrative efforts were primarily in
research, Steele’s in clinical care.
When Blaisdell left for the UC Davis School of Medicine, Sheldon and
Trunkey were the obvious candidates to succeed him as chief. When Paul Ebert,
then chair of Surgery at UCSF, asked Blaisdell’s advice, he was told that it was
like asking which he favored of two sons—Blaisdell could not choose between
them. He told Dunphy that, in terms of politics, Trunkey was probably the best
outside man, and Sheldon the best inside man. Trunkey might do more to
advertise the Department, but Sheldon would accomplish more within the
institution.
This opinion could be debated because Sheldon subsequently occupied
nearly every possible position of merit in Surgery and Medicine. He left SFGH
in 1984, when he was appointed chair of Surgery at the University of North
Carolina. He became Secretary, President, and Regent of the American College
of Surgeons; President of the American Association for the Surgery of Trauma,
the American Surgical Association, the Association of American Medical
Colleges, and the Society of Surgical Chairmen; and chair of the American
Board of Surgery. In fact, he is one of the fewer than 20 surgeons to be President
of all the major surgical societies. He has received numerous honors and awards,
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including honorary membership in the Royal College of Surgeons of Edinburgh
and the Royal College of Surgeons of England.
Donald D. Trunkey
Don Trunkey finished his residency
in 1971 and, with Dunphy and Blaisdell’s
encouragement, went to Parkland Memorial
Hospital in Dallas, Texas for training in shock
research under Dr. Tom Shires. He was
recruited back to SFGH in July 1972. Initially
Trunkey was a bit reluctant to return, possibly
because he was not eager to compete with
Sheldon—surprising as that may seem!
Trunkey also received an FTE to replace the
one lost when Tom Hunt moved full-time to
the Parnassus campus. His shock research was
funded by the NIH Program Project Grant. His
laboratory technician during this period was Mary Ann Carpenter. (For
Trunkey’s biography, see Chapter IV.)
Frank Lewis
Frank Lewis completed his training
in 1974, and with Art Thomas’s assistance,
secured
an
extracorporeal
membrane
oxygenation (ECMO) grant, which initially
supplied his salary. When the ECMO grant ran
out in 1976, there was no support available for
his salary other than professional fee income.
The issue of retaining Lewis was discussed
with the faculty. There was a risk that salaries
might have to be cut if an increase in income
the following year did not cover Lewis’s
salary. Everyone agreed that despite the risk,
Lewis should be appointed, and he was added
to the full-time faculty on soft money in 1976.
Fortunately, income from grants and
professional billing more than adequately met salary and research needs in the
next two years. (For Lewis’s biography, see Chapter V.)
Additional staff support
After Blaisdell’s appointment, Dunphy helped out staff coverage by
assigning a visiting fellow from Australia, Bruce Conolly, to SFGH on January
1, 1967. Conolly, who stayed for one year, was a well-trained young clinical
surgeon from Sydney Hospital. He took a share of emergency and elective
coverage and, in addition, became fascinated with hand surgery. When Gene
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Kilgore made his once-a-week rounds on the Hand Surgery Service, Conolly
participated, and he observed Kilgore’s private practice, as well. Upon his return
to Sydney, Conolly established Australia’s first hand service at Sydney
Hospital—one that subsequently received worldwide recognition.
During the initial years of Blaisdell’s tenure, his NIH grant in
Cerebrovascular Disease, which had been used to start the vascular fellowship at
the VA, continued at SFGH. The fellows served as junior attendings and helped
follow the vascular cases. Lou Buscaglia, who completed his UC chief residency
in June 1968, came with Blaisdell as a vascular surgery fellow. Peter Braunstein
and Tom Maxwell provided additional staff support as fellows in the years
1968-1970. The last clinical fellow was Robert Allen—Bob was essentially a
fellow in trauma, as his year was spent organizing the ambulance paramedic
program.
SURGICAL SPECIALTIES
In 1966, the status of the surgical specialties and their subsequent
development was as follows.
Anesthesia
Longstanding problems related to a lack of adequate anesthesia staff
had been resolved in 1960. Under the new University-County contract
negotiated by Leon Goldman, money was provided for Anesthesia Services. The
UC Department of Anesthesia, under the leadership of Stuart Cullen, placed a
full time member of their Department, Ernest Guy, at SFGH and then initiated
the rotation of anesthesia residents.
Guy was a strong leader and had the respect of the surgeons. He was
elected chief of staff in 1967 and initiated planning for the new hospital. He
abruptly quit one day in 1970 and without any explanation returned to his home
in Georgia. The University had turned strongly academic, and his professorial
advancement in the full-time system presumably had been turned down.
After quite a prolonged search, Phil Larson, an associate professor in
the Department, was appointed to succeed Guy. Phil was a rising star in the
Department at UC. He delayed his coming for about six months and, during that
interval, was offered and accepted the position as chair of Anesthesia at
Stanford. However, Larson agreed to come to SFGH for a year or until the
position was filled.
In 1972, Barrie Fairley, who was chief of Anesthesia at the VA, agreed
to take the job. Barrie was outstanding. He was strong both clinically and
administratively and became medical director and associate dean in 1978. Barrie
was a Canadian-trained anesthesiologist who also had training in internal
medicine. He had definite ideas about fluid therapy: “Keep them dry.” In this
regard, he was in conflict with the surgeons. Also, when he consulted in the
ICU, which he frequently did, he criticized fluid management because he
believed, as many did, that the respiratory distress syndrome was due to
congestive failure from too much fluid and blood.
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Regardless of his differences with the surgeons, his relations with them
were excellent. He was respected and he, in turn, respected the surgeons. With
the introduction of the Swan-Ganz catheter around 1975 or 1976, he changed his
opinion about surgery’s “fluid mismanagement.”
Hand Surgery
Hand surgery during this period was
superbly covered by Eugene Kilgore and William
Newmeyer. Both Kilgore and Newmeyer were
excellent and stimulating teachers and served on a
volunteer basis, providing superb clinical care to
myriad patients with hand infections and injuries.
Gene (see photograph) had acted as the primary
consultant for this Service since the early 1950s,
and in the course of doing so encouraged many of
the residents and fellows whom he encountered to
enter his specialty. These included Bruce Conolly,
the leading hand surgeon in Australia, and William
Schecter and Robert Markison, all of whom served
on the SFGH faculty.
Eugene Kilgore
Orthopedics
Orthopedics was one of the few surgical specialties that had switched
over to full-time coverage by 1966. During the 1940s and 1950s, Frank Cox was
chief of Orthopedics on the Stanford Service. Ted Bovill had finished his
training at Michigan in 1954 and joined Cox in practice. When SFGH moved
toward full- time coverage in 1961, Ted accepted a full-time position in the UC
Orthopedic Department and became chief of Orthopedics at SFGH. His
expertise in fracture management served as an important part of the Trauma
Program development. Ted was such a gentleman that there was never any
conflict between surgery and orthopedics.
Mike Chapman joined Ted Bovill when Mike finished his training in
1975. When Lorraine Day finished her training in 1977, she was added to the
group.
Bovill, with Chapman’s assistance, pioneered in the immediate fixation
of fractures. This was the key to successful management of blunt trauma. Until
aggressive orthopedics came about, most long bone fractures, specifically pelvis
and femur, were treated by traction, which required prolonged immobilization in
bed with all the associated complications. The Surgery Department recognized
very early that the optimum time to stabilize fractures was as soon as possible
following the injury and encouraged the orthopedists’ aggressiveness. This
concept was given further support when Don Trunkey returned from Texas with
the information that immediate fracture fixation was also being carried out at
Parkland Hospital.
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Although extremely controversial at the time of its introduction, this
“radical new method” markedly lowered the incidence of mortality and the
serious pulmonary complications in patients with long bone fractures.
Neurosurgery
Neurosurgery was a major problem for the new Trauma Service
because the dramatic increase in injury cases had resulted in a need for better
neurosurgical care. Initially in this period, neurosurgical coverage was provided
by neurosurgeons from the community. For the first five or six years of
Blaisdell’s tenure, he begged the Neurosurgery Department to provide full-time
staff.
Finally, this was accomplished when Charles Wilson was appointed
chair of Neurosurgery. Charlie, an extremely competent surgeon and
administrator, developed an outstanding program at UC. In 1974, he recruited
Julian Hoff, a brilliant young neurosurgeon, to lead the SFGH program. Buz, as
Hoff was known, brought a research program on head injury that was added to
the Program Project Grant. Above and beyond that, he fit in beautifully with the
young staff. He essentially functioned with the help of only a chief neurosurgery
resident, but now neurosurgical problems were well covered.
Urology
Frank Hinman was chief of SFGH Urology in 1966. Frank’s father had
been chair of Urology at UC, and Frank had been a candidate for that job. When
he was not selected, he remained in private practice and volunteered his services
at SFGH. Hinman was extremely productive academically in his specialty and,
in 1960, melded the two University SFGH Urology Services into one. Of all the
services that were still covered by part-time attendings, there was no question
that Hinman did the best job. He had little interest in participating in trauma, but
he did respond when there were complex bladder and urethral injuries. He
retired in 1976, about the time of the move into the new hospital.
Jack McAninch, a military retiree, was
recruited in a full-time position as Hinman’s
successor in 1976. This proved to be an outstanding
appointment, as McAninch was dedicated to trauma.
His service has been considered the number one
Urologic Trauma Program in the Country. McAninch
was recognized in his specialty by subsequent
appointments as chair of the American Board of
Urology and as a regent for the American College of
Surgeons.
Jack McAninch
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Otolaryngology—ENT
Volunteer clinical faculty ran the ENT service during most of this
period. Initially, it was not a particularly aggressive department, and its staff
were not eager to participate in treating maxillofacial trauma. However, in
1974—when Francis A. Sooy, the previous chair, became Chancellor—the
University recruited a new Department chair, Roger Boles. Boles was from the
Iowa School of aggressive surgery. He brought a major head and neck cancer
program to UCSF, and ENT wanted their share of cancer patients, both at the
University and particularly at the County. In 1975, he recruited Roger Crumley,
a young ENT surgeon from Iowa, who was assigned full time to SFGH. Roger
was well trained in trauma and got along well with everyone. In 1979, Roger left
to become chair of ENT at UC Irvine.
Plastic Surgery:
While all other specialties were becoming full-time departments at the
University, Plastic Surgery remained a division of the Surgery Department. This
division was one of the last to participate in the full-time system. It had been
run, since its inception, by a clinical plastic surgeon, Dr. Harry M. Blackfield,
who was based at Franklin Hospital. Blackfield was a giant in the field, and only
after he retired was the way open for a full-time Plastic Surgery Division at UC.
The first full-time UC chief of Plastic Surgery was Steve Miller, who
was a recent graduate of the program. The clinical attendings, who had been
trained by Blackfield, never gave Miller the respect that was his due, and Miller
ultimately left for another academic job in the Eastern United States. As soon as
Miller was appointed chief in 1974, the entire volunteer faculty served notice
that they were too busy to cover SFGH. Miller personally did his best to help
SFGH—plastic surgery expertise was badly needed to help in reconstruction of
burn and trauma cases.
In 1978, Luis Vasconez, an outstanding reconstructive plastic surgeon,
was recruited to take over the division. Lou Vasconez developed a nationally
recognized program and shortly thereafter provided full-time plastic coverage
for SFGH.
INITIAL SURGICAL SERVICE ORGANIZATION
In 1966, when Blaisdell returned to SFGH as chief of the Blue Service,
Carl Mathewson—Matty—was chief of the Gold Surgery Service. Matty would
be retiring within two years and, in the interval, turned over administrative
responsibility for both services to his protégé. The UC and Stanford volunteer
faculty were combined. The volunteer staff, who had covered the emergency
weeks on both services, abdicated emergency coverage. At this point, the fulltime staff—initially only Blaisdell and Hunt—covered the emergency room
cases.
Until Blaisdell’s arrival, the primary clinical coverage of the residents
had been by volunteer clinical faculty. They represented former trainees of the
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UC and Stanford programs and, as such, were among the leading surgeons in the
Bay Area. They took call in rotation for one to two months a year, made rounds
with the residents one or two times a week and assisted the senior residents with
difficult cases. It was up to each individual attending to decide how tightly or
loosely the cases were supervised. The senior residents, in turn, were responsible
for supervising and teaching their juniors. The chief resident was in charge of
the day-to-day running of the service and organized the teaching conferences
and the distribution of operative cases among the housestaff.
Blaisdell established the rule for the attendings that they should be
present in the operating room any time there was the potential for major
complications or death. This rule for the volunteer faculty remained and was
also applied for all staff when the formal trauma service was initiated in 1968.
At this point, all but a few of the volunteer attendings were phased out.
Medicare required demonstrated supervision of residents if the hospital was to
bill for patient care. This rule required that attendings put operative and followup notes on the charts of all patients. Those attendings who remained provided
specialty services, such as John Anlyan in head and neck cancer surgery and
Gene Kilgore in hand surgery.
OUTPATIENT CLINIC
Until 1967, there were no organized clinics at SFGH except for a few
specialized areas such as pediatrics, psychiatry, and tuberculosis. Until Stanford
Medical School left San Francisco, Stanford and UC vied with one another to
provide indigent outpatient services, and the County administrators saw no
reason to assume any financial responsibility for outpatient care. After the
Stanford Medical School moved to Palo Alto, the burden for outpatient indigent
care was thrown on UC, and its clinics were overwhelmed. For the next five
years, UC insisted that the County Supervisors assume financial responsibility
for the provision of outpatient services and develop the appropriate clinics to
handle the County’s load. It was not until November 1965 that the County Board
of Supervisors came up with the necessary funds.
At that point, planning for the clinics needed to be initiated and a
budget developed. The Department of Medicine was not interested in outpatient
clinics and the planning burden fell to the Surgical Service and was assigned to
the newly arrived Tom Hunt. Hunt developed the proposal for Medical and
Surgical Clinics, which involved the use of the nursing home facing 23rd Street.
The basement of Building 90, which housed ob-gyn and pediatrics, would be
used for their Clinics. The Family Practice Program existed only on paper.
In July 1966, a plan had been developed and a budget was proposed
and accepted by the Supervisors. Just before opening the remodeled nursing
home, the Board of Supervisors cut funding for personnel in half, and the issue
was whether to accept the partial budget or tell the County to forget it. The
medical staff, led by the Surgical Service, held firm. The staff would not open
the clinic with an inadequate budget. Finally, the Supervisors capitulated and
restored the budget, and the clinics were opened in January 1968.
94
When the clinics were first proposed, the plan was to recruit a clinic
director who would develop a family practice program, as the Department of
Medicine, from the start, indicated that they could not staff full-time general
clinics. Hunt—who had been the primary developer of the clinic proposal—by
that time was being pushed hard. He was trying to run the wound-healing
laboratory at UC, tend the Gold Service, and administer the mixed surgical
internship. It was decided to recruit someone to run the Surgery Clinic on the
part-time salary that was available from the City. As the Department of
Medicine did not want to take initiative for organizing their clinics, the Surgery
Service recruit, Muriel Steele, was placed temporarily in charge of all clinics—a
position that carried a full-time salary.
Muriel Steele’s appointment proved to be an outstanding decision in all
respects. Steele was an excellent administrator. When Don Fink was finally
recruited in 1972 as overall outpatient director, he asked Steele to remain in
charge of the Medical and Surgical Clinics while he developed the Family
Practice Program and the city outreach clinics. After Steele’s death, the Surgery
Clinic in the new hospital was named after her.
MISSION EMERGENCY
During its entire history from 1915, when the brick hospital opened,
until 1966, the Emergency Service had occupied the first floor, west of the 22nd
Street entrance of the Emergency building. In 1966, Mission Emergency
Hospital (MEH) remodeling, which had been ongoing for some two years, was
completed, and the service moved from the west wing to the east wing. The
remodeled emergency area contained a large resuscitation room on the right
(south) side and two smaller treatment rooms on the left. In the back were an
eight-bed female holding area and a 12-bed male holding area, both large, open
wards. There were two jail cells for psychiatry patients and a pediatric
evaluation area. The main nursing desk was situated in the center of all the
activity. The operating rooms were conveniently located on the second floor and
were accessible though a small central elevator.
Gladys Jones, the chief nurse during the period 1966-1976, retired at
the time of the move into the new hospital in 1976. However, the dominant force
was Mrs. Margaret Fogler, the evening head nurse. The evening was when most
of the action occurred, and Mrs. F. was always on top of everything. If she
suggested that a resident should look at a patient, the resident had better do so.
Fogler could size up a situation at the bat of an eyelash, and she rarely made a
mistake. When she was around, the surgical staff had full confidence that there
would be order and discipline, and no nonsense. When she reached the
obligatory retirement age in 1975—what a great loss!
During Bill Silen’s tenure as chief of the Blue Surgical Service in the
early 1960s, the responsibility for the emergency room (ER), which had been
administered for the nearly 100 years of its existence by surgeons, had been
passed to the Department of Medicine. Silen had little interest in the ER and
Norman Sweet, a very nice, elderly internist, was put in charge. He was not an
effective administrator, and he had problems controlling his own residents, let
alone the surgery residents.
95
Blaisdell expressed shock at the disorganization of staff coverage and
the lack of supervision of the housestaff. He started lobbying, almost
immediately on his arrival, to reclaim administrative responsibility for the
Emergency Service. As it was recognized that things were not going well, his
request was granted within six months of his appointment.
Bob Lim joined the staff in July 1978 and was appointed chief of
Mission Emergency. The surgical staff made it a rule to start morning rounds in
the Emergency Department, and the faculty member on call looked in again in
the evening before going home. What this succeeded in doing, in addition to
bringing discipline to the area, was to capture surgical material that would have
otherwise been missed. Often these were incidental to the patients’ complaints—
for example, hernias that needed fixing or rectal problems that would have been
ignored; and there were patients with gallbladder disease whose symptoms had
resolved, but who would still benefit from cholecystectomy.
Lim was just the right person to provide the oversight and organization
Mission Emergency needed. With his
appointment, administrative coverage
was insured and remained so until
1984, when the Surgery Department
gave up its responsibility for MEH.
Lim’s relationships with the nursing
and housestaff were superb, and
morale during his tenure was high.
MEH needed the discipline that
Surgery could provide. Moreover,
Mission Emergency was the “spice”
that made the hospital a unique
Critical Emergency Coming In
training experience!
Lim encountered many administrative problems, particularly in dealing
with the Medical Service. Medical Service residents wanted to work up patients
in the ER, even when a patient obviously needed admission. These patients kept
the beds filled and strained the nursing staff. The problem in MEH was
complicated by the advent of “The Boozer Cruiser.” This came about when
director of Public Health Frank Curry defined alcoholism as a disease rather
than a criminal condition. Until then, alcoholics found on the street had been
treated by jailing. Now, instead, a City ambulance was designated to patrol San
Francisco’s Tenderloin District and bring in alcoholics for fluid resuscitation
and sobering up. Lim negotiated with the Medical Service to allow the ER staff
to admit patients over the protests of the residents and persuaded the Medical
Department to develop a sobering-up ward to which alcoholics could be
admitted.
Lim negotiated an agreement with all services that a six-hour stay in
MEH was the maximum time allowed for any patient. At the end of that time,
“If still in doubt, admit.” In order to deal with the patients with minor problems
who were presenting to the ER, he established an experimental drop-in clinic,
manned primarily by nurses. This drop-in clinic was such a success that it was
continued as standard practice, and an acute care clinic became an essential part
of the new hospital emergency room.
96
Mission Emergency was an exciting place to be. It was a “black box”
of interesting problems that challenged diagnostic and technical skills. Until
1966, it was the only emergency room in the City. However, the private
hospitals soon found that, with the introduction of MediCal, the ER was a source
of revenue and hospital admissions. Gradually, between 1968 and 1975, all the
major hospitals in San Francisco, including UC’s Moffitt Hospital, opened
competing ERs. Nonetheless, because the City ambulance system was the prime
responder to all major emergencies and would transport cases only to Mission
Emergency, the SFGH emergency room maintained its monopoly on serious
cases.
THE NURSING SERVICE
The Nursing Service at SFGH had been outstanding in the 1960s and
before the mid 1970s, when it was led by an exceptional director of Nursing,
Irene Pope, who recruited experienced, and highly competent nurses to fill the
senior positions. However, the nursing leadership took a militant stand in 1974,
insisting that supervisory nurses should be required to have a Master’s degree.
This requirement was resisted by the political structure and, when it became
obvious that the Public Health Department would not support it, the nursing
leadership resigned en masse, effectively decapitating their Service. The leaders
of the nursing administration that followed initially lacked the experience of
their predecessors.
THE INTENSIVE CARE UNIT
The remodeling of the last of the clinical towers, the Ten Building, that
closest to the Mission Emergency building was completed in 1966, just as
Blaisdell arrived. The wards, which had previously been labeled alphabetically,
after remodeling were labeled by numbers. Ward 12—the second floor of
Building Ten—had been remodeled as a Medical-Surgical intensive care unit
(ICU). Initially, the Department of Medicine had little interest in participating in
the ICU. Until 1970, when Hibbard Williams became chief of Medicine, it was
the exclusive province of Surgery. From that point on there were occasional
general medicine cases
admitted to the ICU, but
by that time the Coronary
Care Unit
had been
developed in the 30
Tower, together with a
Pulmonary ICU in the
Tuberculosis building.
Initially, the ICU
was used for postoperative
management of major
surgical cases. As the
caseload
in
trauma
increased,
it
became
dominated by patients
ICU Rounds circa 1968. Blaisdell, Lewis & ICU Nurse
97
with major life-threatening injuries. The ICU, first at the VA and now at SFGH,
served as Blaisdell’s clinical laboratory. Before recognition of the acute
respiratory distress syndrome (ARDS), which emerged gradually in most
medical centers during the period 1966-1970, most deaths following critical
illness were ascribed to heart failure, about which little could be done. The
introduction of blood-gas monitoring during this period documented that most of
these surgical patients developed cardiac arrest as a result of hypoxia. The
treatment of this “lung failure” was tracheal intubation and positive-pressure
ventilation.
Blaisdell had been one of the first surgeons to recognize and publish on
the significance of this condition. While still at the VA, he and Robert Lim,
together with Albert Hall, had described it as a complication following shock
associated with ruptured aneurysms, other critical vascular emergencies, and
cardiac surgery. Now at SFGH, it was apparent that, following major injury and
especially in those cases associated with shock, respiratory failure occurred that
was similar to that previously seen at the VA. At that time, there was great
controversy as to whether this syndrome was simply due to overenthusiastic
fluid resuscitation—the view Francis Moore, professor of Surgery at Harvard,
espoused—or whether it was due to a leaky vascular system with actual
hypovolemia, as Blaisdell’s group had maintained. This issue produced some
crucial conflicts at SFGH, as the Department of Anesthesia refused to believe
the problem was due to anything but overenthusiastic fluid administration. The
result was that the Surgical Service had to ensure that patients were fluid primed
before being taken to the operating room and then fluid resuscitated again after
the operation.
Part of the controversy related to whether urine output should be used
as the guide to resuscitation, as the Surgical Service espoused, or whether
pushing all the fluid required to maintain urine output was responsible for
drowning the lungs. If fluid was not pushed, renal failure resulted, whereas—in
theory—raising pulmonary vascular pressure sufficient to provide urine output
would increase fluid extravasation in the lungs.
The controversy was promoted by the fact that, before the Swan-Ganz
catheter was developed, the guide to resuscitation was considered to be central
venous pressure (CVP). If CVP was normal, it was thought that lack of urine
output had to relate to renal toxicity, not hypovolemia. However, experimental
and pathological studies carried out at the VA and subsequently at SFGH by
Lim and Blaisdell revealed microemboli and inflammatory changes in the lungs.
This was consistent with microvascular obstruction and it was found that if
right-sided filling pressures were raised, systemic perfusion increased and renal
failure could be avoided.
The advent of the Swan-Ganz catheter, around 1976, resolved the
controversy by demonstrating that left-sided cardiac filling pressures were low
when renal failure occurred, and raising right-sided pressures sufficiently to
normalize left-sided filling pressures restored renal function. In other words,
patients were in systemic shock when urine output was minimal and proper
shock resuscitation lessened overall morbidity and mortality. The Surgical
Service pointed out that, when renal failure occurred, mortality rates
98
approximated 50%, whereas isolated respiratory failure was associated, at worst,
with a 20% mortality rate.
Initially, ICU staffing was solely the responsibility of the Surgical
Service, but the Anesthesia Department insisted that they needed a role in order
to obtain approval of their training program. Joseph Lee was the first anesthesia
staff member. He joined the ICU in 1969. He shared responsibility with
Blaisdell and brought his expertise in endotracheal intubation and ventilator
management to the ICU. In 1971, he returned to his home in Toronto, Canada,
and Richard Schlobohm was recruited as his successor. Schlobohm was slower
to buy into the Surgical Service concepts. He and Blaisdell reviewed the cases
together and he finally agreed that the respiratory distress syndrome was
characterized by a diffuse increase in vascular permeability. They published the
first article clearly defining abnormal lung capillary permeability as the factor
differentiating it from high-pressure pulmonary edema associated with
overenthusiastic fluid resuscitation and/or cardiac failure.
The SFGH ICU was one of the first joint ventures in the United States.
Initially, the shared disciplines were Surgery and Anesthesia. Later, when the
ICU moved into the new hospital in 1976, a young internist joined the ICU
team. George Sheldon, and then later Frank Lewis, participated as junior ICU
attendings.
THE RESIDENCY PROGRAM
From their first initiation in 1879 until 1960, all San Francisco General
internships were rotating. This was a balanced internship designed to prepare
physicians for general practice. The program had grown to 50 positions by
1960—of them, 25 were appointed by UC and 25 by Stanford. After Stanford
abandoned its services at SFGH in 1960, its internships were converted to what
were called mixed internships, one with a medical and one with a surgical
orientation. The mixed medical internship emphasized medicine but still
included two months of surgery, and the mixed surgical internship had four
months of medicine and the rest surgery. There were no focused internships in
pediatrics, gynecology, psychiatry, tuberculosis, or infectious disease.
During that period, the internship was separate from the residency,
and—during the middle of their internship—those interns wanting further
training needed to apply for their residency. If they were not accepted by UC, or
if they wished to go somewhere else, they had the problem of taking time off
from their internship to interview. There were twelve mixed surgical interns at
SFGH, of whom four to six might be accepted by UC for the surgical residency.
The VA Hospital originally had its own surgical residency but no interns, as was
also true of the Public Health Hospital and the Children’s-Presbyterian
Hospitals.
UCSF had a straight surgical internship that had six intern positions.
However, at that time, in 1966, UCSF accepted 12 to 18 residents for the first
year of the five-year residency. In the late 1960s and early 1970s, many of the
residents went into a surgical specialty after one or two years of general surgery
training. Others went elsewhere because, in 1966, there was still a pyramidal
99
system at UCSF that ultimately narrowed down to six chief general surgery
residents. By 1966, the UC residency consisted of rotations to Moffit, Franklin,
SFGH, and the VA. In 1968, Children’s Hospital was added to the UC rotation
when Victor Richard’s combined Children’s-Presbyterian residency was melded
in.
The mixed surgery internship at the County was the responsibility of
the surgical chiefs. Bill Silen turned the administration of this program over to
Tom Hunt when he left in April 1966. The mixed surgery internship was melded
into the UC straight internship in 1968, when the American Board of Medical
Specialties required that all specialty internships be incorporated into their
respective residencies.
Dunphy initiated a required research year for the UC residency
program in 1966. When a resident elected to take two years in the laboratory,
another resident—usually an outstanding one—was allowed to skip research
training. This was true in the cases of Sheldon and Trunkey, both of whom
skipped research years during their training.
SFGH and the VA were the two places in the system where the
residents had a chance to assume responsibility. Some residents had the feeling
that no one was looking and they did not have to respond to the same discipline
that was expected at the University hospital. Before the institution of full-time
staffing at the VA and SFGH, discipline of residents depended pretty much on
the chief resident. Strong chief residents and those who had empathy for their
patients did not permit any foolishness, but the weaker residents and those who
had little empathy might allow or tolerate it.
In 1966, SFGH was particularly vulnerable to the patients’ perceived
quality of their care. In theory, now that Medicare and Medicaid were available,
patients did not have to come to the County Hospital. It was extremely important
that attitudes regarding patients remain upbeat and caring. Surgery ran the
emergency room, and the policy was that—if no one else, chiefly the internists,
would admit a patient who needed hospitalization—then the Surgical Service
would take the patient.
The chief of Surgery made it apparent that he held the chief resident
accountable for the discipline of his team, and failure to maintain discipline
threatened banishment from SFGH. The good residents needed no reinforcing of
this policy, but to ensure that there was no discrimination, Blaisdell made it a
point, during nearly every chief resident’s initial tenure, to lay down the rules to
him or her in front of the ward team. By indicating that the chief resident was
personally responsible for maintaining discipline, the chief resident’s hand was
strengthened. This ensured that the Surgical Service would be respected by the
hospital staff and by the patients. There were two unpardonable crimes: failure
to treat patients with respect, and gross dishonesty. Repeat offenders—who
fortunately were very few—were banished from the hospital. Lack of
competence was not a reason for dismissal if it was felt that the resident was
working hard to improve.
Teaching activities were held primarily on Wednesday mornings.
Grand Surgical Rounds were held in the old amphitheatre above Mission
100
Emergency. Tumor Board and Pathology Conference followed. At noon, there
was Chest Conference in the old Tuberculosis building where, first, William
Lister “Lefty” Rogers and then, later—Art Thomas presided. Elective Surgical
Conference was held late in the afternoon, at which time the operations
proposed for the following week were presented and discussed.
Grand Rounds in Surgical Amphitheatre
It was during this period of the 1960s that there were remarkable changes in the
SFGH housestaff. The student activism at UC Berkeley was being reflected by
activism on the part of the interns and residents. The introduction of Medicare
and MediCal, and the resulting insistence that there be only one standard of care,
resulted in a change in the attitude of the interns. Why should they work for
nothing when they were providing essential medical care? Why should their
education be compromised by doing menial jobs, such as running down xrays,
making patients’ appointments, transporting patients to and from xray, drawing
blood, and starting IVs? Angry meetings ensued and, although wages were a
critical issue, the conservatives in the group felt it would be self-serving to put
their demands for higher pay above the needs for better patient care.
The precipitating incident, which rapidly became a cause célèbre in
1967, was housestaff parking. At that time, the designated spot for interns’ and
residents’ parking was in the lot behind the 30-40 Building. When others began
to park in the lot, the interns bought a lock and chain and barred the entrance to
the parking lot. Hospital administrators cut the chain and insisted that the
housestaff did not have exclusive parking rights. This situation precipitated a
mass demonstration and a threatened strike, and all the other issues were
brought into play. The administrators panicked and assured the interns that their
demands would be met. The wrangling went on for several years, with different
administrative bodies promising to meet, and others denying, the housestaff
requests. One year, it would be the Board of Supervisors who approved, whereas
the Mayor disapproved. Other years, the Department of Public Health would
101
“forget” to put the item in the budget submitted to the County Board of
Supervisors.
Meanwhile, the arguments among the interns and residents went on.
Could they, as doctors, legitimately refuse to provide patient care? Finally, in
1970, they hit upon a plan: the “Heal In.” In this plan, they would refuse to
discharge patients. The first “Heal In,” lasted four days and brought agreement
to raise housestaff salaries, hire ward secretaries, increase the number of
orderlies, and start a phlebotomy service. In order to fully accomplish their
goals, another “Heal In” was required in 1971. Now, for the first time, interns
and residents received a living wage and their work environment was markedly
improved.
Nonetheless, the housestaff were not completely satisfied. They took an
anti-establishment attitude, abandoned residents’ and interns’ whites for
informal wear that included tie-dyed T-shirts and even partial military uniforms.
One resident wore a gun belt in which he kept his medical armamentarium. They
demanded positions on all the hospital committees and issued a newsletter. This
activism persisted during almost all of the 1970s, but gradually became less
strident and implacable.
One notable event occurred when the housestaff were being courted by
the Teamsters Union. The Teamsters offered to demonstrate their effectiveness
by their ability to obtain representation for housestaff on the Hospital Executive
Committee.
George Sheldon, a resident at the time, was asked by the UCSF Dean’s
office to represent the School. The meeting occurred under Union procedures,
with each side sitting on opposite sides of the table. Sheldon noticed that the
Family Medicine resident, who had been carrying a picket sign, looked very
uncomfortable, so during a break in the dialogue he checked with the SFGH
Dean’s office. They provided the information that the Joint Commission on
Accreditation of Hospitals (JCAH) allowed residents’ representation on the
Executive Committee. Moreover, the Family Medicine resident at the
negotiating table that day was the designated resident to the Executive
Committee—but actually she had attended fewer than a third of the meetings!
When the Teamsters' demands became unpleasant and the moment
seemed propitious, Sheldon asked the resident if she were not already a
representative on the Executive Committee. When this was confirmed, the
teamster just looked at her, picked up his papers and walked out.
Through all of this activism, the surgical residents were the
conservatives in the group. They continued to wear their white uniforms and
respond to authority. As such, they acted as a modifying force against the
activism of their medical colleagues, particularly since it was recognized that
their work hours far exceeded that of any of their colleagues.
The chief residents during this period were on a long leash, which still
included independent operating and decision-making. That aspect of resident
training has been gradually lost. However, tighter supervision and accountability
has not hurt the quality of the product. Blaisdell demanded accountability. He
would support residents if they communicated well and acknowledged errors.
102
His approach to patient care and the resulting imprint on his graduates is without
equal.
MEDICAL STUDENTS
The medical student core clerkship in Surgery was based at SFGH, and
the clerkship was run first out of Silen’s office and then Blaisdell’s office. Under
SFGH's leadership, the core curriculum was laid out, lectures organized, student
rotations determined, and final exams made up. Teaching at the medical student
level has always been most difficult because the cycle is repeated at least four
times every year, and it is hard for staff to maintain enthusiasm when—every six
to eight weeks—the cycle starts over again. Even though the surgical staff at
SFGH carried the bulk of the medical student teaching load, they maintained
their enthusiasm for teaching. In addition, the Department as a whole did well
because Dr. Dunphy was an excellent teacher, and his example was a stimulus to
the entire faculty.
While on their 3-month clinical clerkship during the third year, the
students spent half their time at SFGH. The other half of their rotations was
spent at Children’s Hospital, the VA, or Moffitt Hospital. Blaisdell’s secretary
collected all the evaluations and, after Department Committee concurrence,
submitted the final grades for the students. The staff at SFGH consistently won
outstanding teaching awards, both within the Department and school-wide.
During these 12 years, while SFGH ran the core surgical teaching, the
curriculum went through a number of cycles, from lectures, to no lectures using
case teaching methods, and then back to lectures again. Based on student
evaluations, the conclusion was that change, in whatever direction it goes, is
refreshing. By abandoning lectures after four or five years, then coming back to
them with a new series of lectures and a new group of enthusiastic faculty,
ensured a stimulating teaching environment. This variation avoided some of the
burnout that resulted when faculty gave the same lecture over and over again.
The case method works well but was more demanding for the faculty, as it
required a far greater time commitment. In any case, the students did very well
on the surgical section of National Boards, as demonstrated by the fact that
average grades in Surgery were higher than in any other department.
THE TRAUMA SERVICE
Blaisdell conducted weekly staff meetings that were usually an analysis
of how the service was running. The introduction of full-time surgical clinics in
1978, combined with a marked burgeoning activity in the Emergency
Department, made it apparent to the staff that reorganization was needed. The
two mirror Blue and Gold services had to be changed to accommodate these
conflicting activities.
The SFGH Surgical Program was reorganized on a formal basis on
July 1, 1968. Until then, each service had only a one half-day follow-up clinic,
which was held in the basement of the 90 Building, as were all other clinics.
Now it was necessary to run full-time morning and afternoon surgery clinics.
103
The demands of the emergency service made it difficult to ensure that surgical
staff and residents were available to cover regular clinics. This problem was
compounded by the fact that the number of trauma emergencies was escalating
dramatically. The Viet Nam War protests started in 1966 and continually
escalated as the “flower children” flocked to the Haight-Ashbury District of the
City. This influx brought with it the drug culture, which almost overnight
changed the City from a benign place to a city associated with violence.
Carl Mathewson had
been interested in trauma, and all
of the Stanford attendings had
been part of his military unit—
the 59th Evacuation Hospital—
during World War II. When it
was suggested that the Gold
Service be converted to an
exclusive
Trauma
Service,
Mathewson was ecstatic and
supportive, as was Dunphy. In
addition, the chair of Surgery
brought the news that NIH was
encouraging the development of
Trauma Centers and was about to start funding research into trauma.
Dunphy helped the reorganization by assigning several more junior
resident positions to SFGH, who were used to increase the capability of the Gold
service. From that point on, its primary responsibility was to be limited to
Mission Emergency. It would have two half-day trauma follow-up clinics to run,
but the remaining clinics would be the responsibility of the Blue Service, now
called the Elective Surgery Service.
The Blue Service became the service that had responsibility for
covering the clinic and ward consultations. All of its admissions would come
from these sites. One second-year resident was assigned to cover the clinic full
time. The clinic was organized on the eastern one half of the second floor of the
Nursing Home. Each faculty member was assigned a full day of clinic coverage.
Muriel Steele supervised the area and kept after the surgical staff to meet their
clinic assignments. Gradually, because of different interests developing among
the faculty, specialty clinics emerged. For example, one of Blaisdell’s two halfday clinics was made into a Vascular Clinic. Steele had an interest in Colorectal
Surgery and developed a thriving clinic. Lim had developed a major vascular
access practice, so he ran a subset Vascular Clinic to look after those patients.
Sheldon ran a Nutrition Clinic, and
TRAUMA 1972-73
Trunkey covered the Trauma
San Francisco General Hospital
Clinics.
The initiation of the
Trauma Service was timely. The
City was going wild—police
officers were being shot, bombs
were set off in the police
department; there were riots in the
Auto accidents 5,606
Assaults
3,400
Stab wounds
1,050
Gunshot wounds 756
Total (two years) 9,806
104
Haight-Ashbury District and at San Francisco State College. The Trauma
Service was constantly in the news.
The Trauma Service consisted of two teams of interns and residents.
Each team worked days one week and then nights the next, switching every
week from days to nights and vice versa, as had been the case when two services
were involved. Robert Stallone was the first trauma chief resident, and he helped
a great deal in advising how the residents should be organized. Later that year,
John Mehigan, when he was trauma chief resident, pointed out that the 12-hour
shifts weren’t optimal because there were so many critical patients that it took
too long to jointly round twice a day. Therefore, he and Sheldon were charged
with the responsibility of civilizing the call schedule as much as possible. The
trauma residents’ rotations were changed to 24 hours on and 24 hours off. The
entire team would make morning rounds. The night team would finish any
operating room cases they had pending and clear any cases they might have
referred to the morning clinic, after which they could go home. The chief
resident, as had been the case in the past, was required to stay in-house, but
now—instead of every other week off, as had been the case when there were
Blue and Gold services—the chief spent two months straight in the hospital.
Federal recognition of Trauma Centers began in 1971-1972, and SFGH
was one of nine in the first group so designated. Since California’s Senator
Cranston had sponsored Trauma Center legislation, he was invited to dedicate
the unit; which he did in April 1972. Mayor Joseph Alioto, director of Public
Health Francis J. Curry, and president of the San Francisco Board of Supervisors
Dianne Feinstein participated. Emily Black, head of the Trauma Grants Section,
represented NIH.
TRAUMA CENTER DEDICATION
Monedero, Blaisdell, Senator Cranston
105
The “320 Club”—the chief residents’ suite—was the only saving grace.
It was a nice suite of rooms in the northwest corner of the third floor of the
Administration Building, and it became the social club for the hospital. The
Friday afternoon and evening TGIF (Thank God It’s Friday) parties were the
social event of the week. When Brent Eastman was chief resident, he persuaded
the hospital engineers to install an improve telephone system and a television in
the room.
Trauma Resuscitation in Mission Emergency
Neil Olcott, Peter Noyes identifiable
The Trauma Service was so exciting and so busy that the chief resident
was never bored, and over the years there were very few protests about these
two months of confinement. Alternatives were suggested from time to time to
relieve some of the captivity. The senior residents voted down all suggestions. It
had become a “macho thing”—something that the women residents also wanted
to continue.
Each of the two in-house trauma teams was led by an intermediate
resident and had two interns plus one or two senior students as acting interns.
Two intermediate residents covered the emergency room (ER), each working
12 hours on and 12 hours off. Two surgery interns supported each ER shift.
During the late 1960s and early 1970s, the planning and construction of
a new SFGH was constantly under attack. The County Medical Society had
lobbied against the bond issue for the new hospital before it was passed in
November of 1965. From that time on, the City’s private hospital lobby, as well
as some conservative physicians and politicians, kept up constant agitation,
declaring that the new hospital was unnecessary. “At least,” they suggested, “the
planning for the new hospital should be delayed until the full impact of
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Medicare and MediCal has been realized.” Due to changes in health care
delivery, San Francisco’s private hospitals were having financial problems and
had many empty beds. A number of private hospitals closed. Thanks to the
publicity SFGH was obtaining because of trauma care, SFGH was being
recognized as a community resource. The attitude of the public was, “You might
not want to go there for routine care, but if anything should happen in the way of
accident or injury, that was the premier hospital in the region, if not the United
States.”
Several private hospitals initiated moves to compete with the SFGH
Trauma Program. Presbyterian and Franklin Hospitals were two that were
particularly active. Presbyterian managed to get private ambulances to monitor
the police radio and, of course, “…if they just happened by the scene before the
city ambulance got there, they had no choice but to pick up the casualty and take
it to the closest hospital.” However, this plan came abruptly to a halt when one
celebrated case taken to Presbyterian was so badly mismanaged that the
malpractice threat led them to back away. Moreover, Mathewson, in his
retirement, was running their Surgery Clinic, and he came through loud and
clear with the point that they had no business trying to take care of trauma.
Franklin Hospital—now Ralph K. Davies Medical Center—was
another matter. George Monardo, RK Davies Hospital director, was bound and
determined to open a Trauma Center. When his own staff indicated they would
not support a trauma program, he tried to recruit some of the SFGH faculty by
offering ludicrously high salaries, fortunately without success. The issue that
finally prevented its development was that the community surrounding his
hospital lobbied successfully against his attempt to establish a helicopter service.
In 1971, the California Legislature passed the Paramedic Act. Cardiac
resuscitation in the field was being proposed and the cry was, “the nearest
ambulance to the nearest hospital.” Clearly, victims needing cardiac
resuscitation represented the entire cross section of the older community. Most
were medically affluent, as Medicare covered them. The City ambulance system
was the prime responder to emergencies and transported only to City facilities,
resulting in critical time delays when patients were under Cardiopulmonary
resuscitation (CPR).
Moreover, the private ambulance system, led by George Angotti—
owner of two of the private companies—was way ahead of the City ambulance
system in implementing a paramedic program. Unfortunately, at this critical
time, the City ambulance system was vulnerable because it was without strong
leadership.
In 1969, Bob Allen finished his UC chief residency in Surgery. Before
starting his surgical residency, he had run an emergency program in Lansing,
Michigan. He was the ideal person to develop a training program for
paramedics. Allen was recruited to do this, helped by a stipend from the City
and by a grant from the Robert Woods Johnson Foundation. He developed the
paramedic course that was based at John Adams Community College in San
Francisco. As part of Allen’s recruitment, Blaisdell proposed that he be given
full authority over the ambulance system, which at that point was being run by a
senior ambulance technician. The director of Public Health, Frank Curry, would
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not accept this. As a compromise, Allen was given responsibility for staffing the
City’s “Emergency Hospitals” (better called “First-aid Stations”)—Central,
Alemany, Park, and Harbor—which also served as ambulance bases.
The situation with the City ambulance system gradually went from bad
to worse. There was Union resistance to requiring that all the ambulance
personnel be paramedic trained. The Trauma Program was threatened by the
policy proposed by the private sector, “The nearest ambulance to the nearest
hospital.” Every hospital wanted to be a Base Station (Communication Center)
for its district. As a result, early in 1977, Blaisdell volunteered to take a
sabbatical and run the ambulance system. He would do a study and make
recommendations about how the City ambulance system should be organized to
interdigitate with the private ambulances and meet the needs for cardiac care.
The new director of Public Health, Mervin Silverman, who succeeded
Curry in 1977, didn’t understand what was going on but could not refuse the
offer for Blaisdell to serve voluntarily as acting medical director. So, from
July 1 to December 30, 1977, Blaisdell took his first sabbatical and was given an
office in the Department of Public Health. He spent time at all the Aid Stations,
rode the ambulances, listened to ambulance attendants gripe sessions, and met
with the Hospital Board and with the City/County Committee on Emergency
Care. He compiled a report that recommended, first and foremost, hiring a
medical director for the ambulance system. In addition, he recommended that
the private ambulances should be included in the system and Base Stations
should be limited to a maximum of three. The citywide “Aid Stations” should be
closed and they should be used only as ambulance bases. The exception was
Central Emergency, which had the rape facility and the communication system
and was in an area of need. As the result of the report, an effort was made to hire
a medical director, but the City salary available was not competitive for a
physician. Donna D’Acuti, chief nurse at MEH, was appointed director. She
served from 1979-1988 amidst much controversy, but she succeeded in ensuring
that all ambulance attendants were paramedic trained.
Trunkey was on Trauma call the morning of the bus accident in
Martinez, California in 1976, in which 29 of 51 children died. Trunkey sent San
Francisco ambulances, together with Frank Lewis, to the scene and triaged
several patients back to SFGH. The Board of Supervisors called for a hearing,
intending to discipline Trunkey for dispatching municipal resources to another
county. Fortunately, Marguerite Warren—a large, outspoken woman who was in
charge of the County Disaster Committee—appeared in Trunkey’s defense and
gave the Supervisors such a bawling out that they sheepishly concurred with
Trunkey’s action. This and a number of major incidents related to a cable car
accident in which several passengers were injured, as well as the shooting spree
at the Golden Dragon restaurant in 1977, called attention to the need for disaster
planning. Blaisdell asked Trunkey if he would serve, and Don did with
enthusiasm. Trunkey got along famously with Marguerite Warren, and they gave
local politicians hell. This led to Trunkey’s promotion to the California State
Medical Society Disaster Committee, where he became chair. Shortly thereafter,
however, he was asked to step down because he was considered too contentious.
Later, he was involved with the State Office of Emergency Services and became
chair of their Disaster Committee.
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EXTREMITY SERVICE
Within a year of its formation, the Trauma Service became large and
unwieldy, with rounds being required on as many as 50 to 60 patients. In the
1960s and 1970s there was a parallel epidemic of the complications of drug
abuse—most of these patients required admission to the Surgical Service for the
treatment of extremity cellulitis, abscesses, and septic thrombophlebitis.
Tom Maxwell, the third of Blaisdell’s vascular fellows at SFGH, was
impressed with the number of arterial complications of drug injection.
Inadvertent arterial injection resulted in extremity gangrene and false
aneurysms. His paper reporting his findings received considerable national
notoriety.
Gene Kilgore, the hand surgeon, called attention to the fact that
extremity cases were being neglected. Extremity injuries and the abscesses and
drug problems had a low priority in the overwhelmed operating room.
Moreover, the attention of the attending staff was focused on the life-threatening
injury cases.
As the result, the Extremity Service was initiated in 1970 in order to
decompress 20 or so cases from the Trauma Service. A third-year resident and
an intern were placed in charge of this new program. Even though pus
predominated, the service had a wide diversity of operative cases and provided
excellent teaching of the basic principles of surgery, including hand surgery.
The Extremity Service had its own group of attendings in plastic, hand,
and general surgery. At that time, all hand cases were part of general surgery.
Some time in 1977-1978, orthopedics began to share in the hand cases because
their specialty certification Board required experience in hand surgery.
BURN UNIT
The initiation of the Burn Unit at SFGH was typical Trunkey. When
Trunkey returned from Parkland Hospital, he came with an interest in burns.
Parkland Hospital had established one of the first major burn centers in the
United States, and Charles Baxter, its chief, was one of the leaders in the field of
burn care. SFGH had always taken care of burns, but this was not done in any
organized fashion. Burn isolation was carried out on one or more of the private
rooms off the surgical wards.
When Trunkey proposed that the Surgical Service initiate a burn unit,
Blaisdell encouraged him to talk over his proposal with the hospital
administrator, Charles Monedero. Trunkey found that Monedero was dead set
against the proposal for financial reasons, but Blaisdell had not been informed.
Trunkey proceeded to organize a cadre of nurses, got an old bathtub out of the
basement and a Circ-electric bed and carried them to an empty ward. He then
called the Mayor’s office and invited Mayor Joseph Alioto to dedicate the
“Alioto Burn Center.”
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Hiram Polk, Trunkey & Mayor Alioto
Blaisdell, invited Hiram Polk, chair of Surgery at Louisville to come
and give a dedication talk. Assuming everything was in order, he called
Monedero’s office the day of the Mayor’s expected arrival to discuss details of
the dedication. Monedero, much to Blaisdell’s surprise, knew nothing about the
unit and blew a gasket, demanding Trunkey’s dismissal. However, the wheels of
progress that were set in motion could not be stopped. A picture was published
in the San Francisco Chronicle the day after the dedication showing Trunkey,
Alioto, City administrative officer Thomas Mellon, and Department of Public
Health director Dr. Francis Curry in the new Burn Unit, all dutifully smiling.
Alioto never learned about the dispute, and the director of Public Health found
the money to support the new Burn Center.
Trunkey supervised the unit and, for a while at least, it was the only
major burn unit in Northern California other than that run by the plastic
surgeons at St. Francis Hospital. The St. Francis unit emphasized burn
reconstruction and, as a result, they tended to refer all large burns to SFGH, as
they were not at all comfortable with critical care. The success of this makeshift
unit led to the development of, and the move into, a nice, neat Burn Unit in the
new Hospital in 1976. That six-bed unit included what was, by this time, a welltrained group of excellent nurses. Trunkey and Blaisdell served as the Burn Unit
attendings.
Another development was the addition of the Burn Foundation.
Trunkey had met Andrew McGuire at the National Burn Meeting. Andy and his
wife Kay had started a nonprofit foundation in Boston in 1973, directed at
promoting flame-retardant children’s night attire. When they moved to the Bay
Area in 1975, Trunkey, without consulting with anybody, offered the Burn
Foundation the use of Blaisdell’s original lab on the third floor of the emergency
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building. Andy and Kay subsequently expanded their foundation to include the
prevention of injury and changed the name of their activity to the Trauma
Foundation. This Foundation has grown and expanded, encouraged and
promoted by all the subsequent chiefs of service.
OPERATIVE CASES
With Blaisdell’s arrival at SFGH in 1966, there was an initial focus on
his specialty interest at the VA, which had been cardiovascular surgery.
Although Blaisdell gave up cardiac surgery when he came to SFGH, he did
bring a heart-lung machine with him, planning to use it for major thoracic
vascular procedures.
Initially vascular surgery thrived.
The vascular fellows, with the
cooperation of the xray department, did
all the angiography, and an NIH grant for
cerebrovascular research, which involved
a randomized clinical trial of carotid
endarterectomy, ensured that there were a
large number of carotid operations. The
five-year NIH grant study, which was
centered in the Ward 33 solarium,
supported the fellowship. This study
ended in 1972, when it clearly showed the
benefits of surgery and documented that
many
strokes
were
caused
by
Trauma Team in Action
thromboembolism from a
carotid
plaque—not exclusively by carotid thrombosis or occlusion, as was previously
thought. The study then evolved into a randomized study of stroke prophylaxis
with aspirin. Blaisdell transferred the grant to Frank Yatsu, the new chief of
Neurology.
The availability of the cardiac pump that Blaisdell had brought from the
VA facilitated the repair of ruptured thoracic aortas and later led to the trial of
extracorporeal membrane oxygenation (ECMO) for the treatment of acute
respiratory distress syndrome (ARDS).
The Trauma Service faculty pioneered in establishing principles for the
surgery of trauma. These included principles for the management of major
cervical, thoracic, and abdominal vascular injuries. An important contribution
was their advocacy of an aggressive approach to abdominal injury. The
philosophy was, “If in doubt about the presence of an abdominal injury,
exploratory laparotomy is indicated. Patients don’t die of surgical exploration—
they die of unrecognized injury.” John West, Trunkey, and Lim reinforced this
philosophy in their 1979 publication in the Archives of Surgery. The paper
called attention to the high incidence of patients who died of unrecognized but
treatable injuries in population centers without an organized Trauma Program.
This paper stimulated a nationwide development of Trauma Centers.
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The indications for and consequences of splenectomy were studied and
led to conservatism directed toward spleen preservation. The Trauma Service
was a leader in establishing principles for the management of liver injuries and
developed a technique for isolation and treatment of massive liver trauma.
Principles were developed for liver resection for trauma and for tumors of the
liver. Pancreatic injury was found to be a challenging problem, and guidelines
for its management were established.
The SFGH faculty called attention to the high mortality rates associated
with complex pelvic injuries and encouraged the orthopedic service to initiate
immediate operative stabilization for this as well as long bone fractures. Internal
iliac artery embolization was developed as a way of managing pelvic
hemorrhage. The importance of colostomy and rectal washout in preventing
fatal sepsis following compound pelvic fractures was another contribution.
The surgeons initiated heminephrectomy for selected renal injuries and
did the first ex-vivo repair of renal vascular injury. They performed the first lung
transplantation in the Western United States. They advocated an aggressive
approach to the management of head injury.
SFGH surgeons were among the first to perform adrenalectomy for the
treatment of aldosterone induced hypertension. They developed a technique for
the stabilization of the chest wall in flail chest injuries, and they identified air
embolism as a complication of penetrating lung injury and defined when
operation was indicated.
RESEARCH
When Blaisdell arrived in 1966, there was no laboratory bench space
available for the Surgery Department at SFGH. Both Silen and Hunt did their
laboratory research in the labs at UCSF. Blaisdell negotiated for and received
the third-floor solarium in Building 30 for his cerebrovascular research, and the
third and fourth floors of the Mission Emergency building for his clotting
laboratory and for use in recruiting. The Hospital’s Clinical Laboratory had used
this area until the old Isolation building had been remodeled for the new
Laboratory that had opened in 1964. Pat Lewis, then the wife of Frank Lewis,
served as Blaisdell’s initial laboratory technician. She was instrumental in
helping him set up his coagulation laboratory on the third floor of the emergency
building. .
Frank Hinman, the chief of Urology, had one of the laboratories on the
fourth floor, but by 1968 it was not being used, and it was reassigned to Bob
Lim. George Sheldon, as part of his recruitment in 1971, was given the
laboratory on the fourth floor in the northwest corner. Later, the Trauma
Program Project Grant group and its administrative staff occupied the space
under and behind the third- and fourth-floor amphitheater. The amphitheater
itself was used for Grand Rounds, conferences, and medical staff meetings.
In September 1967, the new Pathology building was completed. The
third and fourth floors were built as animal research laboratories with NIH
funds. The Dean appointed Blaisdell director of the new unit. This unit, which
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was to be used primarily for animal research, was christened the Physiological
Research Unit. At this point, Blaisdell moved his coagulation research
laboratory into the main third-floor lab, and Tom Hunt initiated a wound-healing
laboratory in the other main third-floor lab. The fourth floor consisted of animal
operating rooms and animal holding areas.
The new Physiological
Research Unit served the Surgery
Department very well from the
start. When it first opened, a nurse,
Sue Lyon, was recruited to
administer it. It was made available
by contract with anyone wanting to
work with large animals. A
standard charge was initiated that
provided sterile packs, supplies,
help, and—if a researcher needed
them—anesthesia, skin closure,
and postoperative care.
Physiological (Animal) Research Unit
(Upper two floors of Path Building)
After organizing the Unit, Lyon became bored by her job, and she left
in 1971. Peter Lindquist, a technician who had been working on an electrical
anesthesia project with anesthesiologist Robert Smith, took over the job and
remained in charge of the labs during this period. Pete was a good administrator
but occasionally took too much initiative on his own. He would contract out and
provide service to do most anything for a price, including animal operations.
Because of their mutual interest in coagulation, Blaisdell had been
advised to meet Paul Aggeler, professor of Hematology, when he first arrived at
SFGH. Aggeler had a large coagulation laboratory funded by the NIH and was
the discoverer of factor IX in the clotting cascade. He was also an expert on
coumadin anticoagulation. Aggeler graciously lent one of his Ph.D. researchers,
Jean Robinson, to Blaisdell. Then, in 1971, when he was dying of cancer,
Aggeler helped transfer his laboratory to the Surgery Department.
The coagulation laboratory, under Blaisdell, was staffed by two
technicians, first supervised by Jean Robinson and then by Charles Graziano.
The clinical studies from this laboratory were the first to describe the syndrome
of disseminated intravascular coagulation (DIC) in surgical patients. It defined
the nature of the bleeding syndromes associated with massive trauma and the
need for platelet transfusion. It demonstrated a relationship between
intravascular coagulation and the acute respiratory distress syndrome (ARDS).
Starting in 1974, in an attempt to better define intravascular
coagulation, the laboratory concentrated on measuring fibrinogen metabolism.
Even when patients were supposedly anticoagulated by the clinical criteria of
the day, fibrinogen half-life studies showed that many of those patients still had
evidence that intravascular coagulation was continuing. This finding led to
Blaisdell’s radical concepts about the necessity for using massive doses of
heparin to treat pulmonary embolism and ischemic limbs. This program was
moved to UC Davis when Blaisdell left SFGH in 1978.
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On his return from Sweden, Lim also continued his regional shock
studies. He documented that a defect in functioning platelets was the most
common cause of diffuse bleeding following shock requiring multiple
transfusions.
A Trauma Program Project Grant was submitted to NIH in 1968. This
program put together Blaisdell’s research on intravascular coagulation, Tom
Hunt’s work on wound healing, and Bob Lim’s platelet research, plus an
Anesthesia and a Urology proposal.
In the first review, led by William Shoemaker, approval was deferred,
as all of the projects had to average to a competitive score. The grant was
revised to eliminate the marginal projects and was resubmitted. This time, the
Program Project Grant, reviewed by a team led by William Drucker, was funded
in 1969. It was renewed in 1971 and included a proposal for studies of red cell
2,3 diphosphoglycerate (DPG) by George Sheldon, who had just accepted a
position in the Department. This grant also included support for the coroner,
Boyd Stevens, who was doing complete autopsies on all the trauma patients.
George Sheldon returned from
Boston in 1971 with interests in oxygen
transport and surgical nutrition. His initial
studies, funded by the Trauma Program
Project Grant, were related to DPG changes
in transfused blood and the adverse affect on
oxygen transport. Sheldon also obtained
research funding from the Department of
Defense for his oxygen transport studies,
which formed the basis of a natural
relationship with the Military in the area.
George Sheldon & his lab tech Cindy
Sheldon’s interest in intravenous
nutrition provided a breakthrough in the care of massive injuries and soon
became the primary focus of his research. Thanks to the development of
intravenous nutrition, many patients with critical injuries survived who never
would have survived before. Sheldon initiated and ran a hospital-wide nutrition
service. His basic research was done on a tethered rat model that he developed
during his first year at SFGH. The model provided the ability to compare enteral
and parenteral feeding of similar substrate. The work showed that—in humans,
as well as animals—the gut is an immune organ. Patients not fed enterally, but
fed parenterally, lose their host defense mechanism. Sheldon had a continuous
influx of research fellows; almost all of whom went on to outstanding academic
careers (see Appendix).
When Trunkey returned from Dallas in 1972, he brought with him a
technique for sophisticated shock studies that he had mastered while working
with Tom Shires at Parkland Hospital. The technique involved cannulating and
measuring the electrical potential changes in a living cell during shock. These
studies documented that shock was associated with significant intracellular
water and electrolyte shifts. These studies were carried out in the new
Physiolgical Research Unit.
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Frank Lewis had performed research on a membrane lung before and
during his residency. He joined the staff
as a fellow in 1974. He was recruited to
participate in the national study of the
use of extracorporeal membrane
oxygenation (ECMO). This technique
was being proposed as treatment for
refractory lung failure from acute
respiratory distress syndrome (ARDS).
Lewis became interested in the
pathophysiology of ARDS, which led to
his developing a sophisticated means of
measuring lung water (see Chapter V).
Carol Miller, Ph.D. was
recruited from the Immunology
Department at UC Berkeley in 1973.
Miller had a joint appointment with UC
Berkeley and the Surgery Department.
Lewis runs ECMO
Her trauma immunology program
occupied the laboratory immediately adjacent to the coagulation laboratory on
the third floor of the Physiology Research Unit. This was the same laboratory
used initially by Tom Hunt. During her tenure from 1973-1980, she supervised a
constant flow of graduate students who helped with the research. Carol Miller’s
work on the immunology of trauma was funded in the next Trauma Program
Project Grant’s renewal. Her principal staff collaborator was Robert Lim.
The Trauma Program Project Grant had three renewals during this
period, the last for the five-year maximum. Don Trunkey and Carol Miller’s
research proposals were added to the grant at the third renewal.
Although the coagulation research portion of the grant went with
Blaisdell when he left for UC Davis in 1978, the remainder of the Trauma
Program Project Grant remained intact, with Sheldon as the principal
investigator. Sheldon remained principal investigator of the Training Grant from
the National Institute of General Medical Sciences (NIGMS) until he left to
become chair of Surgery at the University of North Carolina. The Trauma
Center at SFGH was among the first centers in the United States to receive
National Research Service Awards from the NIH. These awards assured funding
for two research fellows annually. During the period of Blaisdell’s tenure, the
faculty published well over 300 papers on trauma, in addition to many other
publications not related to trauma.
THE NEW HOSPITAL
The move into the new SFGH occurred in August 1976 and constituted
a dramatic change in the quality of the environment. Instead of wards, there
were now single and double rooms. The old-style open wards, even though they
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had been made into cubicles during the decade of remodeling in the 1960s, had
not been comparable to the private rooms in the private hospitals.
The operating rooms on the second floor above Mission Emergency in
the old hospital were wide open with no doors. The attendings could walk into
surgery in their street clothes and peer into the operating rooms. The new
operating rooms had protective positive-pressure ventilation and a closed sterile
system, and there was rigid enforcement of sterile principles. Nonetheless, it was
of interest to note that the wound infection rate—which had previously met the
standards of the American College of Surgeons (ACS)—was not affected one
iota.
The patients were better off and their morale was better in the new
environment. However, the nursing staff were strained, as it was more difficult
for them to cover the new ground required when patients were isolated in rooms
rather than on wards. This was most obviously the case in Mission Emergency.
The pre-existing personnel in the old MEH could not adequately staff the new
commodious quarters. The nurses needed roller-skates to get around the
numerous treatment rooms, the male and female holding areas, and the new
drop-in clinic. In fact, the opening of the drop-in clinic was delayed for a year
before the necessary personnel could be obtained. However, the physical layout
in the new ICU and Burn Unit was far superior to that in the old hospital.
New Hospital interdigitated with the old during construction
As the census of the hospital had progressively dropped in the years
between 1966-1976, from 1,100 patients to 300-400, there was plenty of space
in the new hospital. The Surgical Service was given Ward 3A for office space,
and Ward 3D provided sleeping rooms for the housestaff, who regretfully
abandoned the old administration building and the “320 Club.”
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FINANCES
Two economic systems co-existed at UCSF. Until 1964, everyone in
Surgery was on the Geographic Full-time System, which meant that the clinical
faculty were allowed to supplement a relatively small University salary with the
income they generated from private practice. Moreover, not all members of the
faculty at UC had University salaries. Even though they practiced full time at the
University Hospital and had clinical titles, many supported themselves entirely
from private practice.
When Bert Dunphy arrived as chair of Surgery in 1964, only three or
four of about six or eight members of the Surgery Department had State a fulltime equivalent (FTE) salaries or any form of state support. The University State
salary was the same for a professor of English or History as it was for Medicine,
and was the same on all campuses. Thus, for practical reasons of retaining
physicians, all clinical faculty had been allowed to supplement their income
from private practice. This “Geographic System” encouraged clinical
commitment and clinical excellence. However, at the University Hospital, it
usually precluded the residents from doing operations on the faculty’s patients.
Only the clinic service, which treated indigent patients, provided cases for the
residents to assume patient care responsibilities. As a result, SFGH and the VA
were of prime importance for residents’ training. At those hospitals, the
residents could be involved in decision making and function as the operative
surgeon.
With the arrival of Dunphy in Surgery at UC, and then Holly Smith in
Medicine shortly thereafter, UC elected to adopt the full-time system. Tom Hunt
and Fred Belzer, Dunphy’s faculty recruits from the University of Oregon, were
the first appointees in this system. Blaisdell was the third. Under this
arrangement, the Department billed and kept the money for any clinical services
that were provided by the full-time faculty and insisted that salaries be written
into all research grants. This provided the money for clinical supplementation,
which was the same for all clinicians in the Medical School and was based on
professorial level.
Internal Medicine thrived under this system—whereas, under the
Geographic System, Surgery had thrived. When surgeons committed themselves
to full-time research, as their medical colleagues did, they couldn’t compete for
patients with the surgeons in the Geographic System. So when they worked side
by side, as was true at UC during this period, the cases tended to go to the
Geographic-funded surgeons. This created a situation in which the academic
full-time surgeons had a problem maintaining their clinical credibility.
At SFGH, everyone was on the full-time system, so there was no
competition for patients. The only problem was to be sure that the surgical staff
were involved in sufficient number of cases to maintain their technical expertise
and clinical credibility. There were six general surgeons on the staff during most
of this period—two covering trauma, two in elective surgery, and two on the
extremity service. The staff rotated services each month.
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Intense faculty involvement was also the key to the recognition of the
Trauma Center’s expertise. It was important that resident graduates respected
the surgical staff as credible surgeons. This respect then diffused into the
community. However, the additional requirements for the faculty to spend time
teaching medical students, as well as be productive in research, was a continuing
challenge and required a dedicated faculty and an extensive time commitment.
The University financial support for the SFGH surgeons gradually
changed. Although Blaisdell was provided with four University FTEs, the
supplement required by the full-time system needed to come from soft money—
either clinical care or research. With the introduction of MediCal and Medicare,
the staff at SFGH could bill for patients’ services that they provided. The
alternative, used by the Medical Service, was to apply for San Francisco City
salaries. However, unless these stipends were for administrative work, any staff
receiving City salaries could not bill for professional services. Blaisdell made
the decision not to apply for City salaries because he felt Surgery could do better
billing for their care. Thus, as the staff increased from the original two—
Blaisdell and Hunt—it became necessary to initiate a billing service.
By the time Bob Lim arrived in July 1968, the Surgery Department had
started to bill for surgical procedures. This meant that the faculty had to put
notes in charts whenever they were involved in an operation, which they had
never done in the past. They had to be listed as the surgeon rather than the
resident. Muriel Steele, who started as a volunteer consultant in July 1967,
agreed to help. When she became a full time faculty member in 1969, she took
over and ran the billing machinery. She was a godsend, as she brought her
knowledge of private practice billing with her. The first year, the Surgery
Department cleared $80,000 after billing costs. The next year, the Department of
Medicine was required by the University to participate in the billing process.
Although Surgery’s billing effectiveness had markedly increased and the
surgeons anticipated at least doubling their income the second year, they were
devastated by the report that, after University billing expenses were deducted,
their SFGH billing had cleared only $10,000.
Evidently it cost far more to generate a medical bill than it brought in.
The bills submitted by the internists were minimal and their notes for their
rounds brought $10 to $20. They billed for few, if any, procedures, whereas
surgical operations were generating a minimum of several hundred dollars a
case. The surgeons perceived that they were supporting a bureaucracy that
required them to spend valuable time on paperwork that generated only a
pittance of income. The SFGH surgeons were told that they had no choice but to
participate in the joint billing process. However, the surgeons stopped signing
notes and, within a month of the third billing year, the combined billing process
was brought to its knees.
The surgeons indicated that they would agree to restart billing only if
they could do so under their own auspices. They informed Dunphy that they
would go it on their own, and that there need be no supplement from the
University other than the four FTEs provided by the Dean. The Surgery chair
readily agreed to this proposition, and the University billing group backed away
and left the surgical staff on its own. Needless to say, billing became quite
effective and, thanks to Steele’s keeping up on all the billing possibilities, a
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healthy cash flow developed. This money, combined with salary money
generated by research grants, permitted funding of research and travel and
substantially augmented base salaries, despite the fact that at least one third of
the patients were not billable. Most of the income came about because of the
development of the Trauma Program, which had a substantial percentage of
third-party payers.
OFFICE STAFF & WARDS
During the period of planning for the new hospital, from 1968-1970, the
SFGH Surgery Department was in a major expansion mode. Until 1960, the
Stanford Surgery administrative offices had been entirely housed on Ward C
solarium (later called Ward 13) and UC on Ward F solarium (Ward 22).
Subsequently, when the ten-wing remodeling was completed, a corridor wing
had been constructed between the Buildings 10 and 20 and private offices were
in place along this corridor. This was where most of the new surgical staff had
their offices. The secretarial staff and students were based in the solaria.
With the increase in the number of the surgeons at SFGH, from Blaisdell
and Hunt, to Lim, Steele, Thomas, Sheldon, and Trunkey, administrative support
had become grossly inadequate. The initial office staff was only a young
secretary named Carol Harris, who in her spare time was a nightclub singer. She
could take care of Blaisdell’s work pretty well, but providing adequate
secretarial support for the others was impossible. A fair amount of frustration
among the staff related to that issue. Ultimately, Art Thomas took matters in
hand and, while Blaisdell was on vacation, recruited a high level administrative
assistant and created some additional secretarial positions. Blaisdell returned
from vacation to find an assertive and dominating woman in charge. She advised
Blaisdell that she would run the administrative aspects of the Department. She
moved Blaisdell into a private office in the solarium. Previously, he had been
accessible to anyone who wanted to see him, as his office door in the main
corridor between Wards 23 and 13 was always open. Now, he was isolated and
protected by secretaries outside his office in the solarium—a much less friendly
situation that he came to resent.
At his first opportunity, he encouraged his office manager to move on and
he strongly supported her successful application for a similar position in the UC
Department of Orthopedics. His office relief came with the move into the new
hospital—once more he ensured that
his office opened into the main
corridor, where everyone could have
immediate access to him.
As the length of stay for
hospital patients decreased and the
number of admissions dropped
gradually, other space became
available. All male surgical patients
were consolidated on Wards 13 and
14. Female surgical and orthopedic
Typical Hospital Ward this period
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patients were located on Ward 24. Male orthopedic patients were located on
Ward 22, and 22 Solarium became the cast room. Ward 23, which had also been
a surgical ward, was closed, so the solarium was available as a gathering place
for the housestaff and students. Ward 23 subsequently became the location of
the Burn Unit. Twelve Solarium was the initial location for the Renal Dialysis
Unit. Eye and ENT patients were placed on Ward 25. Ward 15 contained male
urology patients.
As the new hospital was being designed, the office space that was
planned for Surgery was completely inadequate and made no allowance for
Anesthesia or the full time staff in the surgical specialties. The Surgery
Department indicated that it would prefer to take its chances and remain in the
old hospital. The hospital census continued to fall as the federal programs
dictated shorter and shorter stays for illness. Thus, the hospital that was planned
to accommodate 700 patients had an average census of less than 400 by the time
it was occupied in 1976. As a result, the Surgery Department staff and
administration were allowed to occupy Ward 3A on a temporary basis. Ward 3C
became the location of the male trauma patients. Ward 3-D became the Female
Surgical Ward; Extremity and Plastic Surgery were located on Ward 4B and 4D
was the Elective Male Ward.
STAFF ADVANCEMENT
Blaisdell encouraged the staff to participate and be active in
professional organizations. He emphasized that, in order to obtain membership,
they had to be academically productive. Once they gained membership, they had
a ready outlet for their papers, which led to national recognition. He pointed out
that participation in professional organizations was a measure of academic
attainment, but more importantly it was an opportunity to serve in advocacy
roles and influence the advancement of their specialty.
He continually pressed surgical organizations for membership of his
staff. He nominated his people, as soon as they became eligible, for membership
in the American College of Surgeons, the Society of University Surgeons, the
Pacific Coast Surgical Association, the Western Surgical Association, and, most
importantly, the American Association for the Surgery of Trauma. Some
memberships took unusual directions, such as the founding of the Samson
Thoracic Society by Art Thomas—later to become the Western Thoracic
Society.
The American Association for the Surgery of Trauma (AAST) is an
example of Blaisdell’s influencing an organization’s composition. Historically,
general surgeons had not been the leaders in the field of trauma. The field was
dominated by orthopedists up through the 1960s. In fact, the American College
of Surgeons Committee on Trauma was originally known as the Committee on
Fractures. The AAST had a fixed membership and was an exclusive
organization by nature. By 1970, it was out of touch with the epidemic of
penetrating injuries that resulted from the violence in the cities due to the
protests against the Viet Nam War and the introduction of the drug culture.
When Blaisdell first joined the AAST Council in 1969, the AAST executive
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committee was still composed primarily of fracture specialists. Blaisdell, John
Davis of Vermont, and others met in Washington and rewrote the bylaws. That
revision prescribed fixed terms for officers, and gradually the new general
surgery trauma surgeons came to be in control of the organization. At the AAST
meeting in Lake Tahoe in 1978, Sheldon was asked to be the transitional
Secretary.
Efforts were successfully made to open the membership to the full
spectrum of traumatologists. The organization is today one of the most vital of
all organizations and has assumed the role of the international organization for
trauma. The Blaisdell SFGH group has contributed five Presidents to the
AAST—Blaisdell, Sheldon, Trunkey, Lewis, and Trunkey’s protégé, Anthony
Meyer; three Fitts Orators—Blaisdell, Trunkey, Sheldon; and two Secretaries—
Sheldon and Meyer.
The ACS Committee on Trauma has had as members Trunkey (who
became chair), Blaisdell, Sheldon, and Jack McAninch. The leadership included:
as Regents—Sheldon, Eastman, and McAninch; ACS President—Sheldon; ACS
Vice-President—Julian Hoff; and recipients of the ACS Distinguished Service
Award—Blaisdell, Trunkey. The National Safety Council Award for
Distinguished Service has gone to Blaisdell, Sheldon and Trunkey.
The American Surgical Association has been served by Sheldon as
President and Secretary and by Blaisdell and Trunkey as Vice Presidents.
The Residency Review Committee has included Blaisdell and Sheldon.
The American Board of Surgery has been served by Blaisdell, Trunkey, William
Schecter and Anthony Meyer. Sheldon and Lewis have been chairs of the Board.
Lewis is currently executive director of the American Board of Surgery.
A PARTING DECISION
Dr. Dunphy retired as chair in 1976. Blaisdell was the strongest internal
candidate to replace him. A number of the residents and junior faculty lobbied
for his appointment, but the Dean and Search Committee selected an outside
candidate, Paul Ebert. Bill was disappointed, but conducted himself with
characteristic dignity. It was clear to most of us that he would soon leave to take
a chair position elsewhere. He said that he had done all he could to move the
SFGH service ahead and that, if he were Paul Ebert, he would put all future
resources at the Moffit campus, which needed them more. He said that his
choices at this point were to run for political office, as that was the only other
thing he could do to further promote SFGH, or move.
When the chair of Surgery at the University of California, Davis
became available, Bill nominated several of his staff for the position. He,
himself, was prevailed upon to interview and came back enthusiastic about the
prospects. He said, “It was a Medical School that had hardly been used yet.”
There was a lot he could do. He left for Davis in July 1978 and was to spend the
rest of his academic life at that institution. As a token of appreciation for what
he had accomplished for SFGH, the Surgical Suite was dedicated to him.
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Operating Room Dedication
Sheldon, Mattone, Blaisdell, & Director Windsor
INCIDENTS & ANECDOTES
Strike, Strike, Strike
This period was associated with one strike after another. In August
1966, the first nursing strike in the United States occurred when the SFGH
nurses walked out. They were being paid less than the street sweepers and the
janitors, who were members of strong unions. The next year, SFGH interns
threatened to strike—and two years later they did go out on strike when their
demands, previously agreed to, had not yet been met. A general City-wide strike
occurred the following year. At the height of one of the City-wide strikes,
attempts were made by the Unions to close the hospital down. In order to keep
the hospital running, many subterfuges were resorted to. Hearses were used to
bring in food and supplies through the Pathology Building and its tunnels that
connected to the main hospital. At one point, armed men broke into the
operating room (OR) and threatened to shoot the nurses if they persisted in
working. The crusty nurses simply turned their backs on the strikers, after
warning them that they would be accused of murder if they further compromised
the emergency operation that was underway.
Laboratory Services
Myron Pollycove, director of the new Clinical Laboratory, had an
enormous amount of space, staff, and equipment. However, the housestaff often
found it hard to get a simple blood count, especially after the first of January
when the budget was running low. Pollycove’s response was to initiate the
rationing of lab tests, and he came up with an unusual solution—to dispense
coupons: so many coupons for a blood count, more coupons for a blood sugar,
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and so forth. Unfortunately for the plan, the housestaff—Frank Lewis was an
intern then—quickly found a way to counterfeit the coupons. The interns had a
“lab in”—they drew gallons of blood and overwhelmed the lab with orders for
tests that were fully supported by coupons! “Pollycove about had a stroke!” as it
was impossible to differentiate the counterfeit from the real coupons.
Drug Scene
In 1967, the San Francisco Chronicle newspaper reported that 10,000
young people in the Haight-Ashbury District were using LSD and other drugs.
Bullitt
In 1967, SFGH participated in the movie Bullitt starring Steve
McQueen. Much of the drama was based in the hospital. When a key witness
was wounded, he was admitted through the ER, went through surgery, and was
then taken to the ICU. The emergency room (ER), ward, and operative scenes
featured SFGH residents and nurses. Charles Jenkins administered ER
resuscitation, Bob Allen operated on the patient, and Richard Barber provided
anesthesia. Ward 23 was remodeled to resemble the ICU on Ward 12, and the
equipment was subsequently given to the hospital. When the movie opened in
Times Square, New York City, the marquee outside the theater had a 15-foot
high figure of Dick Barber in his scrubs!
Making a Medical Diagnosis
Understandably, the housestaff did not relish “grummous admissions,”
but Blaisdell established the rule that, if no service would take a patient who
obviously had to be hospitalized somewhere, the patient was to be admitted to
the Surgical Service. However, if the patient could be passed off on another
service, so much the better. If the surgeons could diagnose heart failure, a
possible heart attack, or pneumonia, the patient could be referred to the Medical
Service. One resourceful surgical intern applied tuberculin skin tests to
undesirables. If the tests proved positive, the patient was transferred to the
tuberculosis ward for evaluation and possible treatment—three gold stars!
Hell’s Angels
Over the course of the years, there were a number of incidents related
to the Hell’s Angels. In one instance, one of the bikers was brought in with
massive injuries and was given terminal resuscitation. Meanwhile, a hundred or
so bikers circled outside Mission Emergency, creating a terrific racket. When
they were informed of their colleague’s death, the leader demanded his jacket.
When the jacket was not delivered immediately, a number of bikers rode right
into the ER. The institutional police cowered behind the furniture. Shouting,
“Give them the damned jacket,” was the only help they offered. Needless to say,
someone dug the jacket out of a property bag and handed it over a hot potato.
Green Ink
To facilitate identification of notes for billing purposes, Blaisdell tried
to get the faculty to use green ink. However, the faculty did not take to the idea,
and the use of green ink became the mark of the chief. When he made
unattended rounds in Mission Emergency and found a patient whom he felt
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needed surgery, Blaisdell would put a mark on the abdomen with a note: “Cut
here.” He might even draw an outline with a gall bladder full of stones!
The “320 Club”
The chief residents had a corner suite of rooms on the third floor of the
Administration Building that was affectionately known as the “320 Club” after
the number on the door. There were many incidents involving the “320 Club”
and its renowned TGIF parties. When Blaisdell was chief of staff, he insisted
that hospital administration do something to prevent after-hours assaults and
thefts. One Friday, shortly thereafter, the hospital director proudly informed his
chief of staff, “This weekend we are going to have plain clothes officers all over
the place, and we will solve some of these problems.” At approximately
5:30 PM that Friday, Blaisdell received a plaintive call from his chief resident.
“Dr. Blaisdell, would you please come up to our room? We have just been
raided and we are all under arrest.” It seems that interns who were sent out for
the beer had brought the cases right through the main lobby and were followed
up to the residents’ room by the police. Fortunately, the hospital administrator
was prevailed upon to pardon them. This put a temporary crimp in the Friday
activity.
Crazy On the Loose
The anesthesia service was conducting experiments on electrical
anesthesia in baboons, when one of the animals got loose and escaped out of the
hospital to Potrero Hill. The animal supervisor, Peter Lindquist, ran out into the
street dressed in his hospital greens with his animal rifle loaded with sedative
darts. Shortly thereafter, Blaisdell received a plaintive call from Lindquist:
“Chief, please come and help me. The police have me, and they think I’ve
escaped from the Psych ward.”
Gorilla Terrorizes Potrero Hill
Immediate search for the escaped baboon was unsuccessful, but he kept
appearing in and around the Potrero Hill neighborhood. His escapades were in
the newspapers, with such quotes as: “I saw this gorilla peeping into my
bathroom.” At last, Peter Lindquist received a call from the police—they had the
baboon surrounded. He was in a tree in the park on Potrero Hill. Pete hurried to
the scene, shot his sedative dart rifle at the baboon, and missed—then shot again
and missed; then shot a third time and missed. “Ah hell,” said a disgusted
policeman, who pulled out his pistol. “Bang.” The baboon fell out of the tree.
Pete administered CPR and called the Trauma staff for help resuscitating the
animal —to no avail.
Sore Thumb
One evening, when she came in for an emergency call, Muriel Steele
was attacked in a hospital stairwell by a rapist. The man had met his match.
Steele nearly severed his thumb with a bite. Several hours later, when her
attacker showed up in Mission Emergency for treatment, he was promptly
arrested. Steele suffered little in the way of damage except for her broken
glasses.
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Chef Kairy
The dining room had a policy that, if a resident was going to be late,
someone had to call the dining room to reserve the meal. Otherwise housestaff
could wander in any old time and demand to be fed, disrupting preparations for
subsequent meals. There was one chief resident who arrived late from a sojourn
in the OR and demanded a meal. The altercation reached the level of Chef
Kairy, a large, intimidating man who always wore a chef’s cap and a red
bandanna. The chief resident, who was no match for Chef Kairy in terms of
height or weight, continued to harangue the chef, but the chef kept his cool and,
rather than pulverizing the resident, reported the incident. The resident was told
to go down and apologize. There were plenty of chief residents but only one
Chief Cook!
Luncheon in the Buff
One of the rules adopted was that no one dressed in scrubs was allowed
in the dining room for the noon meal. One surgery resident, straight from a
prolonged morning in the OR, arrived in scrubs and asked to be fed. “Sorry, we
can’t feed anyone dressed in hospital greens.” With that, the resident stripped off
his scrub suit and—standing there stark naked—once again demanded a meal!
Gypsys
An elderly member of a Gypsy clan was operated on and was found to
have inoperable pancreatic cancer. A call must have gone out, because the
hospital was soon filled with Gypsys from all over Northern California. Whole
families—men, women, and children—did not just visit to pay their respects, but
camped everywhere they could in the hallways, in the front and side entrances,
and in any empty room or ward they could find. The staff were besieged
constantly for updates and progress reports. Their vigil did not end until the
patient’s death several weeks later.
A President’s Daughter
Blaisdell had not yet met one of UC’s new interns when he read in the
social section of the newspaper that the intern, who was dating President
Lyndon Johnson’s daughter, had had dinner with her at one of the City’s
prominent restaurants. “A Dunphy political appointee, no doubt,” he commented
to his staff. “That intern cannot amount to much!” He later acknowledged that
was the worst mistake in judgment he ever made. That intern was Brent
Eastman!
Visiting Clinical Professors
Six times a year, the last week of each chief resident’s time on Trauma,
a previous graduate of SFGH’s residency was invited to spend a week as a
consultant for the resident. The “visiting professor” lived in the “320 Club,”
consulted with the chief resident, and helped him or her with emergencies. This
interchange permitted the visitor to catch up with what was new on the Surgical
Service and helped to advertise the Trauma Program. In addition, the chief
resident had the opportunity to ask questions about setting up a private practice.
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Minority Appointment
When Trunkey returned from Texas in 1972, he immediately started
work at SFGH. Several months later, when he still had not received a paycheck
from the University, he consulted with Dunphy. At that time, the University was
requiring a search for members of minority groups as part of every appointment,
and Trunkey’s appointment had been held up to ensure that minority candidates
had a chance to apply for the position. When Dunphy informed him of the
reason his appointment was being held up, Trunkey responded: “Tell them I’m
gay.” Dunphy laughed and processed the application with that announcement.
The appointment cleared immediately without further challenge!
A Desk for the “320 Club”
One evening, when Housekeeping was cleaning administrator Charles
Monedero’s office, his desk was temporarily placed in the hall. When the
janitors took a break, the Trauma team, under Brent Eastman’s direction, moved
it to the “320 Club.” There, it served as the chief resident’s desk until the
residents’ quarters were demolished after the new hospital was completed.
M&M on a Falcon
Blaisdell’s car was a beaten-up Ford
Falcon that he had purchased from UC’s chair
of Pediatrics for $300. When the car finally
died on the street, the residents went out and
took a picture of it with the hood up, and then
presented it as a case report at the
department’s morbidity and mortality (M&M)
conference.
Demise of a Falcon
Poor Leo
One Saturday morning while Sheldon was Trauma resident, he received
a call from his wife Ruth. He was informed that his family had just been to the
Zoo. The kids wanted their Dad to know that they had just seen a lion eat a man.
As they were younger than five years old at the time, Sheldon thought this was a
healthy dose of childhood imagination. While he was still on the phone, though,
he heard sirens and simultaneously received an urgent call to the emergency
room. Once there, he found a man in desperate straits, covered with lion fur
from head to foot. He was an alcoholic street person who had jumped into the
lion pit, falling 20 feet and breaking both ankles. He had crawled over to the
four lions dozing in the middle of the den and hit the youngest one, Tommy, in
the head with a wine bottle. The year and a half-old lion retaliated, inflicting
horrible injuries on the man. A zookeeper emerged with a gun and shot and
killed the lion. The San Francisco Chronicle the next morning had a picture of
the lion with the man’s head in his mouth. The lion’s feet had dug out the man’s
femoral vessels and a complicated repair was required to save his leg. There was
extensive national publicity regarding the event. Letters came in from all over
the country, many from school children, who deplored the fact that Tommy had
been killed.
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Six Shooter
A small boy ran up to an ER intern and said that a man who was
waiting to be seen had a gun. As it turned out, the man had been injured while
escaping from San Quentin—he was a murderer who had killed several people.
The Trauma resident called the institutional police. They indicated they did not
get paid enough to take care of something like this. The resident then called the
hospital administrator, who advised him to call the regular police. Just before the
police arrived, someone else called attention to the gun—at which point the man
brandished the weapon and cocked the hammer. Fortunately, the police arrived
at that moment. An officer managed to get close enough to the assailant to grab
the gun with his thumb in such a fashion as to prevent the hammer coming
down. He wrested the gun from the man and hit him with a crack on the skull—
fracturing the skull and ensuring that he was going to be a patient for the next
several weeks.
Male or Female?
Valerie was a transvestite who was well known to the nurses in the ER.
About once a month, Valerie attempted suicide by ingesting barbiturates but
then promptly called for an ambulance. The nurses usually undressed the
patients, but when Valerie came in, they would call the junior intern instead.
Valerie was gorgeous looking and had fully developed breasts, as well as fully
developed male genitalia. The intern usually emerged from the examining room
in shock.
Presidential Assassination
In 1975, President Gerald Ford was speaking at the St. Francis Hotel on
Union Square when Sara Jane Moore—a 45-year-old bookkeeper who dabbled in
revolutionary politics—fired a bullet at him. The red phone in Mission
Emergency—which is activated when a President is in town—rang with the
information that the President was shot and was being brought to the hospital.
Alarm bells rang, the trauma staff were fully mobilized, and the sirens could be
heard coming down the freeway. However, they went right on past, taking the
President to his plane at SF Airport. The assassin’s bullet had missed!
A Case of Chest Pain
The third-year students would get their assignment for physical
diagnosis, go examine their patient, and then have their examinations verified by
the faculty. Sheldon took a group to see an 18-year-old patient whose complaint
was chest pain on the left side. The assigned student valiantly attempted to
justify his impression that the patient had angina pectoris. Sheldon made the
point that a good approach is always to ask the patient what the patient thinks is
wrong. Correspondingly, the patient was asked what he thought caused the pain
and when did it begin? He responded that the pain started when his girlfriend
had stuck him with a knife. Some angina! Years later, the student involved had
become a popular professor of Pathology at the University of North Carolina
Medical School. When he was selected to address the students at
Commencement, he told them this story.
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The Plumber’s Apprentice is a “Shoe-in”
When the new hospital was opened in 1976, there were immediate
problems—the most notable of these were related to the plumbing system. When
the toilets were flushed on the upper floors, the sewage ran out of the toilets on
the lower floors. The question was whether the drainage pipes were inadequate
or whether some obstruction existed in the main drainage line. If there were an
obstruction, where was it? As the engineers were peering over the blueprints
trying to figure out the problem, Frank Lewis happened by and listened to the
discourse. Frank—never lacking for an opinion on anything—stated
unequivocally as he pointed to the plans, “The obstruction has to be right here.”
The engineers listened to his argument, opened the pipe in the recommended
area, and found a tennis shoe!
Ambulance Resuscitation
The surgical staff repeatedly insisted that ambulances “load and go. Do
not try to resuscitate the trauma patient in the field.” The problem had been
minimal until the paramedic program was initiated—then delays in transport
occurred as the paramedics wished to use their new skills. The staff insisted that
no attempt should be made to start an IV line in the field. “If it must be done, do
it in the ambulance!” The paramedics maintained that this was difficult, if not
impossible. “Nonsense,” said Blaisdell. “I’ll show you.” Whereupon he took an
ambulance call, but he found that his attempts to start intravenous lines were
completely unsuccessful as the ambulance driver hit every pothole in the road.
Differentiating Red and Blue:
When Richard Crass was working as a junior resident in Mission
Emergency Hospital one evening, a patient with a gunshot wound of the
abdomen presented in profound shock. The entire Trauma team was upstairs
operating and so Blaisdell—who was referred to as “the Blazer” by the residents
behind his back—broke scrub to come down and assess the patient. The intern
was having trouble doing a brachial cut-down and Blaisdell elected to help him.
After placement of the line, the IV bottle rapidly filled with blood. Blaisdell
looked up and said, “Richard, you wanted an arterial line, didn’t you?” and
Crass responded, “Yes, Sir!”
Weeks later, this complication was presented at the departmental M&M
conference. Dr. Larry Way commented how much complications like this upset
him. He stated that he could not understand how someone could mistake an
artery for a vein, and that he could even tell the difference on his medical school
cadaver. Blaisdell stood up and told Way that he did that cut-down and that Way
should recall that, in the cadaver, the arteries were injected with red latex and
the veins with blue.
Readmission Policy
When working at Mission Emergency Hospital, it was important to
discharge all patients from the male ward by 4 AM. This would allow this
predominately alcoholic population to move, by “Brownian motion,” far enough
away from the entrance to Mission Emergency that they would not be visible
when Blaisdell arrived in the morning. If Blaisdell saw patients milling around
the entrance to the emergency room with no place to go, he would routinely
bring them back in.
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The Green Phantom
Every surgical resident at San Francisco General feared Blaisdell’s
“green pen.” The work of this pen was evident in notes appearing in the chart at
any hour, day or night, suggesting that a specific patient needed an operation.
Woe be it to the resident who did not find this note. Occasionally, the green pen
made dotted lines on the abdomen of a patient with abdominal pain, with the
comment: “Cut here by (a certain hour).” This was a way that “the Blazer”
could ascertain whether proper serial abdominal exams were being done.
CASES
Complicated Cardiac Resuscitation
A Pacific Gas & Electric lineman was electrocuted while on the top of
a line pole. Believing him dead, his companion cut his belt and the lineman
plummeted thirty feet to the ground, where he let out a moan. He arrived in
MEH alive but required repair of a ruptured thoracic aorta.
Schrock Shunt
In 1966, the Trauma attendings were confronted with several
untreatable liver injuries in which there had been tears of either the major
hepatic veins or the retrohepatic vena cava. Ted Schrock, then a junior surgery
resident, was on rotation to pathology at SFGH. He was given the assignment of
working out the anatomy of the renal veins and the retrohepatic vena cava.
Schrock demonstrated that isolation of this portion of the vena cava was
possible, provided that a shunt could be used to bypass the area. At that time,
occlusion of the cava in a patient in shock was associated with immediate
cardiac arrest due to trapping of blood behind the caval occluding clamp. In
1968, by using the technique worked out by Schrock, SFGH reported the first
successful technical repair of right hepatic vein avulsion from the vena cava.
Ex-Vivo Kidney Repair
In 1967, the Trauma Service was confronted with what appeared to be
an insurmountable problem. A 24-year-old drug addict had been shot in the
abdomen and was found to have suffered a gunshot wound through the hilum of
his only kidney. As renal function was present, he was treated expectantly.
However, on the seventh day after the injury, he developed massive urinary
hemorrhage. Aortography disclosed an arteriovenous fistula involving a
segmental renal artery and vein, with a large false aneurysm in the hilum of the
kidney. At that time, renal dialysis was limited to certain select groups of
patients, and drug addiction was a specific exclusion. The patient was taken to
the OR, the kidney was removed, and injuries to the segmental vessels were
repaired on the back table. The kidney was replaced in the standard transplant
position in the left lower quadrant. The patient regained renal function but died
of sepsis and pulmonary failure several weeks later. Subsequent to this, Bob Lim
performed two additional ex-vivo kidney repairs for fibromuscular hyperplasia
of segmental renal arteries, and the three cases were published in Archives of
Surgery in 1972. Although this was thought to be the first such publication, it
was later found that the Japanese had published such a repair in their literature a
year earlier.
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The Camilla Cox Library
During the height of the Haight-Ashbury hippie period, a young hippie
girl was admitted to SFGH with acute, fulminating, drug-induced pancreatitis.
She developed severe respiratory failure and required multiple debridements of
her necrotic, infected pancreas. Despite many months of heroic therapy, she
ultimately succumbed. This was before intravenous nutrition was introduced.
Her mother, who was from the conservative Midwest, spent most of her time at
her daughter’s bedside and, in appreciation of the care her daughter had
received, asked what she could do for the residents. Her $5,000 donation was
used to start the surgical residents' library, which was established in the chief
residents’ suite of rooms.
Aortic Arch Injury
Shortly after his return from Sweden, Bob Lim was confronted with a
patient who had an angiographically proven rupture of aortic arch vessels
consisting of the innominate left carotid and left vertebral arteries. He
successfully repaired the first two injuries and ligated the third. The patient
survived—the first success reported for this injury.
Splenic Injury Infection
In 1979, Lim reviewed comparable liver and splenic injuries and
reported a peculiarly high incidence of infection complications in patients
following splenectomy, as opposed to corresponding patients with liver injury.
This paper was highly disputed when it was presented at the Pacific Coast
Surgical Association meeting, but subsequently it was recognized to be correct.
SFGH took the lead in conservative treatment, including splenic repair, and
tempered the aggressive use of splenectomy for minor injuries, as previously
had been the rule.
Drug Abuse Tragedy:
One of Blaisdell’s most depressing cases was that of a young, bearded
hippie who was admitted with gangrene of his foot from a femoral artery drug
injection. He was critically ill and Blaisdell said, “As I looked at him, he seemed
familiar and I asked: ‘Don’t I know you?’ I thought he was a patient I had
previously treated.”
He said, “You are right, Dr. Blaisdell, you do know me. I was a
medical student on your service four years ago. After medical school, I was sent
to Viet Nam and, while there, I got hooked on drugs. Look what’s happened to
me since I left the service!”
His foot was amputated and he was given a below-knee prosthesis. It
was later learned that he committed suicide a few months later.
Pain in the Back
A patient presented to the triage nurse complaining of pain in his back.
He was asked to sit on the bench. The nurse said, “The doctor will see you when
he can.” Shortly thereafter a woman on the same bench screamed: “There’s a
knife in that man’s back!” That patient was moved to the head of the line!
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Bullet Embolism
“During the early 1970s it seemed like bullets were flying everywhere,”
and a number of unusual injuries occurred. Among the most challenging of these
were cases of bullet embolism. As a result, the rule was established that entrance
and exit wounds must be counted and all bullets accounted for. Low-caliber
gunshot wounds of the upper abdominal aorta resulted in bullets in the profunda
femoral and popliteal arteries. Caval gunshot wounds led to bullets in the heart
or in the pulmonary arteries
Hepatic Artery Ligation
In 1970, a police officer suffered a through-and-through, right-to-left
gunshot wound of his liver. Application of a portal triad clamp resulted in
control of major arterial hemorrhage. Selective occlusion of the right and left
hepatic arteries established that bleeding was coming primarily from the right
hepatic artery. Ligation of that vessel was associated with control of the
bleeding and an uneventful recovery. During that period of time, hepatic artery
ligation was overused nationally, but in selected instances, such as this case, it
worked well.
Mangled Liver
Norman Christensen, as a “visiting professor,” remembered clearly the
first trauma case of his first week at SFGH. “As I changed into greens in the
dressing room, George Husband—later to become my partner—was changing
out of his. George announced that his chief residency was over and that Ted
Schrock was the new chief resident. In the OR, Ted and I found that the problem
in this case was a badly mangled liver. After lots of blood and unsuccessful
attempts to stop the bleeding, Schrock suggested that we pack the liver. We did
and re-operated the next day to find a dry field. The patient recovered.”
Reluctant Amputee
A young man with a swollen leg was admitted to the hospital. He had
been hit on the thigh with a baseball line drive several days before. There was
obviously a huge hematoma of the thigh, in addition to extensive redness and
swelling. The patient had a temperature of 105 degrees and was extremely toxic.
Biopsy of the thigh revealed foul-smelling dead muscle. The patient was asked
to sign permission for a high above-knee amputation, but he adamantly refused.
He said, “I would rather die than lose my leg!” Despite disagreement among the
faculty, Blaisdell made the decision to proceed with surgery. The patient’s
parents in Boston were contacted, and they gave permission for the operation.
The gas gangrene was treated with high amputation and radical debridement.
After a prolonged postoperative course, the patient survived and expressed his
gratitude for the decision to countermand his initial request.
Living Dead
When Bob Allen was a member of the junior staff, he walked into the
ER to find the residents practicing intubation on an apparently dead patient.
Although no pulse was palpable, Allen thought he saw the patient take a slow
breath. He called senior staff to reinforce his opinion. The patient was alive, but
with a temperature of 70 degrees! Warming resulted in a full cardiovascular
response, but unfortunately the patient did not awake from coma.
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Bad Caval Injury
A memorable case, when Sheldon was an attending, was the case of a
young man who presented in shock after a self-inflicted gunshot wound of the
lower chest. During surgery, an urgent midline abdominal incision was extended
into a sternotomy with a Lebschke knife. The injury was a 270-degree
transection of the supra diaphragmatic vena cava. It was managed by using the
Schrock shunt, which permitted the cava to be sewn back together in a dry field.
The urgent sternotomy had gone off-center into the right chest and disclosed
significant bleeding coming from the right lower lobe of the lung. Accordingly,
a right lower lobectomy was performed.
Sheldon had to leave for a program in San Diego and called Blaisdell to
the OR, asking him to assume the postoperative care. Blaisdell assumed that the
patient would require assisted ventilation in the unstable post-injury setting. To
his surprise, a new anesthesia resident rotating in the ICU had already extubated
the patient immediately postoperatively. He looked up at the shocked Blaisdell,
and said, “April Fool.” It happened to be the first of April. The patient made an
uneventful recovery.
In 1973-1974, a rash of random killings plagued the City. The Zebra
killers and other anti-establishment groups like the Symbionese Liberation Army
exemplified the hostile environment at the time. Of 23 victims, 12 reached
SFGH alive, and eight of them survived. One of these was Art Agnos, then a
social worker. While Agnos was standing in the street discussing the potential
for a new clinic on Potrero Hill, he was shot in the back. His injuries involved
the lung, kidney, and spleen. Trunkey treated him successfully. Agnos later
favored SFGH as a member of the Board of Supervisors and then as Mayor of
San Francisco.
Zebra Incidents
Sniping incidents were a common tactic of the Zebra killers. One
maneuver was to set off a fire alarm and than shoot the fireman riding the
trailing ladder truck. One morning, a policeman was brought into SFGH with a
non-critical injury. He said that he had been shot by a sniper. Anticipating more
victims, the Trauma team assembled in the ER. Soon thereafter, the wail of an
emergency siren was heard. The paramedics brought in a victim with a wound
from a high-velocity bullet between his eyes. Then a SWAT team member
popped into the trauma bay and said, “That’s the sniper—he peeked out of a
window, and we took him out.”
Golden Gate Bridge Jumpers
Survivals after jumps from the Golden Gate Bridge are rare, but they do
occur. One survivor who was admitted with multiple fractures was quizzed
about how he managed to live. He stated, “It was a long way down and—on the
way—I changed my mind about suicide, so I steered myself into the moat
surrounding the tower. Trouble was, there was a lot of lumber in there.”
The Laughing Policeman
In 1973, when The Laughing Policeman was being filmed at SFGH,
Doug Dorner and Don Trunkey treated a patient with a major abdominal
gunshot wound who had an associated vascular injury. They operated nearly all
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day, finishing around 7 PM. At 2 AM, Trunkey received a call from Dorner
saying that the patient was bleeding and should go back to surgery.
Trunkey said, “Go ahead and get started.” There was a long pause at
the other end, after which Dorner asked if Don would come in and do it.
Trunkey and the intern took care of the operation, and then learned that Doug
was downstairs participating in the filming of the movie. Doug had a bit part, for
which he received $400.
The Unloaded Gun
A science reporter from the San Francisco Chronicle newspaper was
given permission to follow the Trauma Service one Saturday evening. A known
psychiatric patient presented in cardiac arrest from a self-inflicted gunshot
wound of the sternum. He was resuscitated in the ER with thoracotomy and was
taken to the OR, where his left ventricular injury was repaired. The patient did
well, and the reporter returned for a follow-up interview for his featured article.
The patient, recognizing his celebrity status, had fully recovered from his
depression. He told the reporter, “I
was just cleaning my gun when it
went off.” This explanation was
accepted at face value.
A Catastrophic Injury
Wayne
Lindblom,
a
construction worker, was essentially
cut in half by a backhoe. Sheldon and
Brent Eastman controlled an injured
aorta, removed the left kidney, did a
hemipancreatectomy, and stabilized a
spinal fracture. Tom Hunt looked in
on the case and offered the opinion that the patient would not make it off the
table, and he went to notify the family. However, the patient did survive the
operation. Blaisdell saw the patient in the ICU and also spoke to the family. He
let them know that the occurrence of both renal and respiratory failure made
survival unlikely. Julie, the patient’s wife, was a naïve and lovely young woman
with great faith. Having been given this information, she said that she did not
want anyone other than Sheldon or Eastman to give her follow-up information.
The patient survived a year long ordeal and the case was featured in an article in
the Reader’s Digest.
A Case of Cardiac Tamponade
Trunkey remembered his first SFGH rotation as a fourth-year resident.
“We were making rounds at about 9 AM, when I got a stat call to go to the
cardiac cath unit. The chief of Cardiology had been helping one of the cardiac
fellows do a heart catheterization for a 49-year-old woman who was suffering
from mitral valve disease. When they inserted the catheter, it penetrated the right
ventricle. When I arrived, the cardiologists were standing at the console,
repeatedly watching the playback of dye squirting into the pericardium, which
was causing pericardial tamponade. Neither one of them was paying any
attention to the patient. She was still conscious, but the nurse was very
concerned that her blood pressure had fallen to 50 systolic. I quickly took a
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knife off the tray and opened her left chest, at which time she screamed, and the
chief cardiologist turned around to see what was the matter. About this time, one
of the anesthesiologists showed up and I said, ‘Intubate her and give her
something for pain!’ Blaisdell arrived at about this time—after assessing the
situation, he said, ‘Here, I’ll help you,’ and we took the woman to the OR and
closed the small hole in the right ventricle. At the end of the case, he said ‘Next
time, you might wait until the patient is comatose and no longer having any
pain.’”
Bringing the Dead Back to Life
Trunkey initiated a program to resuscitate patients who were not
responding to CPR. This program involved putting patients on cardiopulmonary
support by using femoral artery and vein catheterization. Fourteen patients were
placed on the protocol, but resuscitation attempts failed for all fourteen and they
developed massive uncontrollable bleeding as the terminal event. “At that
point”, Trunkey said, “Blaisdell called me into his office and admonished me for
not being able to identify a cadaver when I saw one.”
Malingerers
There were many examples of patients presenting to Mission
Emergency with feigned illness. Mrs. Fogler, the evening nursing supervisor,
was extremely adept at recognizing them and warning the residents. The most
common presentation that came to the attention of the Surgical Service was
abdominal pain, feigned by drug addicts desperate for a “shot.” The most adept
was a patient who had mastered the art of simulating renal colic. Somehow he
managed to introduce blood into his urine specimen. Once he came under
suspicion, he was kept under close observation. Still, his urine contained blood.
At last, an astute nurse noted suspicious motions while he was urinating and
pulled back the covers to reveal that he had been pricking his finger with a tiny
needle taped to his thumb to introduce blood into his specimen.
An Archery Mishap
In 1975, a Native American was brought into Mission Emergency with
a through-and-through arrow in his left buttock. He and some of his colleagues
had been doing a little drinking while practicing archery in Golden Gate Park.
Trauma Recidivism
A young man was admitted shortly after he ingested lye in a suicide
attempt. His whole esophagus dissolved, and he ultimately required esophageal
resection from the cricoid level to, and including, a portion of his stomach. Six
months later, Art Thomas replaced his entire esophagus with the left colon. The
proximal anastomosis, by necessity, was to the lateral pharynx. Months later,
just as he was ready to be discharged from the hospital, he jumped out of a
fourth-floor hallway window. His fall was broken by a metal awning. His
extremity fractures required another six months of hospitalization, at which
point he was transferred to the Psych Ward. One day, he escaped from the ward,
climbed the fire escape to the roof and jumped off. It had rained the night
before, and he embedded himself in the soft lawn, once again escaping with a
few more fractures. Ultimately, after several years of hospitalization, he was
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discharged. It was later learned that he had been murdered on a street in the
City.
Medical Student Self-Triage
One warm spring night, a senior medical student was walking home in
the back of the campus behind Moffitt Hospital, when he was assaulted and
stabbed in the chest. He staggered home and had his wife drive him to Mission
Emergency, where his hemopneumothorax was treated with a chest tube. The
UCSF Chancellor, Philip Lee, called Blaisdell at home to find out why the
student was not taken to Moffitt Hospital. Blaisdell informed Lee that the
medical students knew exactly where to get the best care. The medical student
did well at SFGH, and later continued his studies at UCSF as an orthopedic
resident.
The Golden Dragon Incident
The massacre at the Golden Dragon Restaurant was truly a test of the
SFGH team’s capability in handling a disaster situation. On September 4, 1977,
Chinatown gang activities resulted in a shootout that could be likened only to
the St. Valentine’s Day massacre in Chicago in 1929. Several gunmen entered
the restaurant with automatic weapons and shot up the crowded place,
attempting to kill opposing gang members. About a dozen multiply injured
patients were brought to Mission Emergency at the same time. The Trauma team
had been alerted, and teams of staff were set up to receive them. Bob Lim was
responsible for triage and resuscitation. The most seriously wounded were
immediately transported to the OR. All in all, five deaths resulted.
Later, the Chinese community erroneously accused the SFGH faculty
of discrimination, saying that they took care of white victims first and let
Chinese patients die. One of the Chinese patients was an elderly waiter who had
massive head and neck wounds and was quadriplegic. Blaisdell and Lim went to
face a community tribunal to explain their actions. “After listening to their
grievances, we assured them that all patients were promptly and appropriately
cared for.” Lim informed the group that he and his chief resident—John Boey,
who was also Asian—were the ones who triaged the patients. The protest
immediately died when it was disclosed that members of their same ethnic group
had made the triage decisions. The ultimate result of the complaint was to get
our City fathers to provide more resources for SFGH’s Trauma Program.
The Mayor Visits the ICU
On one occasion, a police officer who had multiple gunshot wounds
was treated in the ICU, together with his assailants. Mayor Alioto was upset and
made a politically motivated, unannounced visit to the ICU. Needless to say, it
was an eye-opener for him, and he became “green behind the gills”—there was
blood and gore all over the place! He made a quick exit before the hospital
administrator could get there. Possibly he was more sympathetic to SFGH’s
cause after that.
The Buddy System
Ward 45 was designated the Municipal Ward for police and firefighters
injured in the line of duty. Whenever they were hurt, their buddy system dictated
that they promptly take care of their own. They were transported by ambulance
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to Mission Emergency under police escort. The violence of the 1960s and 1970s
generated many gunshot injuries between police and the “bad guys.” Often a
downed policeman would be brought in, followed closely by another ambulance
bringing in the bad guy. All the treatment rooms in the ER were in close
proximity—which did not go well with either party. The police wanted to know
why we were taking care of the villain first, even if the bad guy’s injury was
more serious than that of the officer.
STAFF MEMBERS’ MEMORIES OF THE BLAISDELL YEARS
Robert C. Lim, Jr. recalls…
I have known Bill Blaisdell since 1961, when I started my residency
with him at the VA. When I was appointed to the SFGH faculty and he said:
“Call me Bill,” I had great difficulty not calling him Dr. Blaisdell. In fact, when
I heard the residents call him “the Blazer” behind his back—probably with great
affection, or maybe fear—I shuddered because I was always brought up to
respect my elders. However, no matter what he is called, he commands the
respect of his residents and students.
During this period of time, there was a great deal of hostility against the
police. The “hippie movement,” with its anti-war activism and the rampant drug
abuse, made the work of law enforcement very difficult. One of the most tragic
incidents was when someone threw a bomb into the Park Police Station one
evening. The desk sergeant took the
blast directly and was immediately
brought to Mission Emergency. We
intubated him, placed intravenous lines,
and continued resuscitation on our way
to the operating room (OR). A reporter
took our picture as we rounded the
corner to the OR elevator. Captured in
the picture was our trauma nurse, Susan
Miller, who later went to medical
school at Loyola University. She was
the first woman to complete surgical
training at the Massachusetts General
Hospital (MGH). She then did a trauma
fellowship at SFGH. She is now Susan
M. Briggs, professor of Surgery at the
MGH, and is the trauma surgeon in Depiction SF Police circa 1972
charge of the premier International
Medico-Surgical Response Team.
The Riot Squad of the Police Department in the 1970s was called The
Second Platoon. When the “Brown Panthers”—a political group with a
revolutionary agenda—threatened to attack SFGH, the Second Platoon marched
in linear formation, much like Army infantry going into battle in a frontal
confrontation. Although the police carried guns, their principal weapon for
crowd control was a large, long, curved, hickory stick, that—when carried
horizontally—could be used as sort of a fence to push back the crowd. When
they were attacked, the stick could be used as a club. Their helmets provided
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partial protection against rocks and bricks, but they suffered a number of serious
injuries, and several officers were killed.
One of the SFGH medical housestaff went so far as to paint his
motorcycle helmet white with a red cross on it, in order to go though police lines
and be a part of the opposition. He was very outspoken and anti-establishment,
but subsequently he continued his career as staff on the Medical Service at
SFGH.
From the Mission Emergency staff’s perspective, San Francisco in the
1960s and 1970s resembled Iraq in 2007. The police force formed the Second
Platoon to protect the public and public institutions from rioters. Not only were
they involved in the Haight-Ashbury District, where most of the riots were
centered, but they also played an active role wherever the protests against the
Viet Nam War became violent, such as at San Francisco State University. We at
SFGH became very well acquainted with the members of the Second Platoon
because the police, as well as the rioters, were frequently badly injured. The
anti-establishment referred to the police as “Pigs,” and the Second Platoon
adopted the pig as their symbol.
I accompanied Blaisdell to the awards banquet of the Second Platoon
the year he was honored, along with Samuel I. Hayakawa—President of San
Francisco State University. Blaisdell was presented with a police baton and a
bright yellow T-shirt that featured a caricature of a pig drawn as a policeman
with a nightstick. The meeting had the atmosphere of a fraternity party. Bill’s
contribution was obvious. Sam Hayakawa was famous because, as a professor of
English at San Francisco State, he had climbed up on top of a sound truck that
was instigating a riot by shouting blasphemies against the Viet Nam War. He
pulled the wires from the speaker on top of the truck. The incident was featured
on the cover of Life magazine. This single act propelled him to the Presidency of
San Francisco State and then to the United States Senate, where he served from
1977-1983.
Donald Trunkey recalls…
There are lots of anecdotes about Bill. One of my most memorable
times was my very first rotation at San Francisco General, which began in
September of 1966. Three weeks after I began, there were the Hunters Point
riots. I went down to the emergency room because we were starting to get
incoming gunshot and stab wound victims. Bill was standing in the middle of
the old Mission Emergency, and he told me to go outside and do triage as the
ambulances arrived. I walked outside, and the ambulance bay was completely
empty. While I was standing there, I heard the sound of bullets hitting bricks just
above me. I looked up on the hill, and there was a guy standing there, shooting a
.22 rifle—at me, I presumed. I went back inside and Bill asked me what I was
doing there. I explained to him that I didn’t want to get shot at. He didn’t
volunteer to go outside either!
I also remember very vividly getting my ass chewed by Marilyn
Blaisdell—Bill’s wife. In anticipation of one of his Christmas parties, Bill asked
me to assist him in making some beer. After proceeding to make a malt beer,
Bill insisted on putting it in soda bottles. I tried to explain to him that, if we had
residual sugar, which would make the beer nascent, it might cause too much
pressure on the soda bottles, and that instead we should put it in champagne
bottles. Bill insisted on using soda bottles. A couple of weeks later, the beer
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Surgical Staff Clean Up: Lewis,Trunkey, Steele
started breaking bottles in Marilyn’s basement. She informed me in no uncertain
terms that I was never to make beer in her house again.
Although it did not directly affect Bill, I remember that during one of
the nursing strikes we sent a number of patients over to Franklin Hospital, and
even some to the University. We were left with 109 patients in the hospital that
we could not transfer. Bill said that we were going to keep the hospital open no
matter what. The problem then became how to feed these patients and keep
everything clean, as workers—other than the nurses—refused to cross the picket
lines. Bill assigned Muriel Steele and me to the kitchen. We went down just
before lunch to fix macaroni and cheese and sandwiches. Some of the housestaff
delivered the food to the various wards. Although some of the patients were
supposed to have special diets, on that day they had no choice about what they
got.
Afterwards, the housestaff brought down the dishes, and Muriel and I
proceeded to wash them. We couldn’t get the dishwasher to work correctly and
the thing made a lot of noise. What we didn’t know was that there was no rinse
cycle. That evening we used the same dishes and apparently there was a thin
film of soap on all of them. Every single patient who ate dinner that evening got
diarrhea! I thought some of the housestaff were going to lynch us because they
were the ones who had to clean up the mess. Muriel and I were both captured on
film by CBS news, cleaning the kitchen. I had a mop and Muriel was standing at
the dishwasher—Frank Lewis was drawing coffee.
My experience initiating the Burn Unit was described earlier. After we
christened the Burn Center—that same afternoon—Monedero, the hospital
administrator, stormed into Blaisdell’s office demanding that he fire me.
Blaisdell explained that I was getting no money from the County—that I was an
employee of the University and he would have to take it up with the Dean.
Monedero never spoke to me again. Bill thought it was a perfect solution. He
was particularly happy to vex Monedero. When he was voted chief of staff, Bill
asked the faculty what they wanted him to do.
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“Get rid of Monedero” was the unanimous response. I learned that Bill
walked directly from that meeting to Monedero’s office and the following
occurred.
“I have just been elected chief of staff,” Bill said.
“Congratulations,” said Monedero.
“Charles, they elected me with the charge that I was to get rid of you.”
“Do you want me to resign, Bill?”
“Yes.”
“Then I will.”
Monedero had clearly been in over his head and, to his credit, he
recognized it.
I also remember very vividly the day that Senator Alan Cranston
dedicated the Trauma Center in the pathology auditorium. I was on trauma call
and got paged to go to the emergency room. A 16-year-old male at a high school
in the Richmond District had been stabbed. The ambulance had responded and
found the student in shock. The paramedics loaded him into the ambulance, but
it wouldn’t start because the battery was dead. They called for a back-up
ambulance, which took approximately 25-30 minutes to arrive, and then he was
brought to San Francisco General. By the time he arrived, he had lost his vital
signs. He had a single stab wound in the left anterior chest. We immediately did
a thoracotomy, and I was standing helping the residents when Bill walked in
with Dianne Feinstein. Bill apparently was showing her around the emergency
room, and she asked what had happened. There was blood all over the floor and
we were not winning. I think he had been dead too long. I was so damned angry
that I turned to her and I said, “It’s because of you and the supervisors that this
kid is dead. When the ambulance responded, the battery went dead; they don’t
get good maintenance, and they’re old and decrepit. This kid would be alive
today if he had had proper transport.” She turned pale and left the emergency
room.
Blaisdell, in his own inimitable way, looked at me and said, “You’re in
big trouble now, Trunkey.”
I said. “Well, what should I do? Should I apologize to her?”
He said, “You created the problem—you get out of it.”
A little later, Sheldon was in the ER when Francis Curry, the director of
Public Health, appeared. He had been at the Trauma Center dedication and had
been rebuked by Feinstein after her encounter with me. Curry appeared
perplexed, and Sheldon asked if there was anything he could do for him. Curry
snapped, “That Dr. 'Turkey'”—his term—“got me
into trouble.”
I was summoned the next day to go to the
Board of Supervisor’s meeting, where Feinstein
had me recount the episode. They immediately
voted to buy eight new ambulances. I don’t think
even Blaisdell thought it would turn out quite that
way.
I remember the 21-year-old male who was
shot in a liquor store holdup. He was the son of the
owner and sustained two .351 magnum bullet
wounds through and through, in transverse fashion,
across his abdomen. Dunphy was my “visiting
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professor” and was unpacking his belongings in the “320 Club” when I called
him to come to the OR emergently. The patient’s injuries were extensive and
included the cava, aorta, and right renal artery, and he had lost a lot of blood.
Dunphy told Blaisdell the next morning that I was not as good as he thought I
was, and that he was not as good as I thought he was. Blaisdell asked him when
we were going to take the young man back to surgery.
Dunphy said, “There is no reason to take him back.”
Blaisdell said, “Okay, then I will do it.” Bill and I then took the patient
back to the operating room and, when we opened him up, the spleen fell out.
Dunphy, who was watching, said: “Now I know why you guys do these
second look operations” and walked out of the operating room.
Frank Lewis recalls…
I remember the green ink on the charts—the need to make pre-rounds
each morning looking for green ink in the progress notes. Sometimes there
would be green ink diagrams on the abdomen of patients in the Mission.
I remember the sudden appearance of Bill, looking over my shoulder in
the OR at three in the morning.
From the Mission nurses, I learned about a practice they used to
chuckle about. They moved patients out of the male ward across the hallway
into vacant rooms on the other side when Bill was about to make Mission rounds
if they didn't want him to see a particular patient.
I remember an elderly woman with some abdominal pain whom I'd
been watching for several hours, unable to figure out what was wrong with her. I
did not think her abdomen was acute enough to need exploration. Bill made
rounds, berated me for allowing her to sit around with dead bowel, and insisted
we take her promptly to the OR—which we did. At exploration, we couldn't find
anything significant. Afterward, Bill reassured the relatives it was a good thing
that we operated because we proved that everything was OK. This was an
example of how Bill was never reluctant to talk to relatives and assume
responsibility, particularly when things did not go well.
One Friday afternoon, the residents and nurses had gathered in the “320
Club” because one of their patients, a pornography producer, had given them
one of his choice movies. They were all set up to show the movie in the living
room, but Bill had dropped by and was having a good time talking to everyone
and showed no inclination to leave. Finally, someone closed the door to the next
room and started the movie. Everyone gradually disappeared until the only
people left in the anteroom were Bill and I. He thought he must have been
missing something, so he proceeded to open one of the living room doors. He
looked in just in the midst of a particularly graphic scene and suddenly got the
picture. To his credit, he just quietly closed the door and left.
I became interested in the membrane lung because of my engineering
background. In 1970, the membrane lung was under development in many
centers. I spent my research year during my residency in the Donner Laboratory
at Berkeley, working on membrane physiology. As I was completing my
residency, there was a national trial developing under the aegis of Bob Bartlett at
Michigan, using extracorporeal membrane oxygenation (ECMO) to treat acute
respiratory distress syndrome (ARDS). Bill asked me if I was interested in
staying on staff and applying for this NIH-supported grant. My grant application
was successful and provided money for my initial salary.
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When we were doing the ECMO trial for ARDS in the mid 1970s, we
saw an 8-year-old boy who had end-stage pulmonary failure and had been on
ECMO for about a week. His condition was worsening. He kept blowing out his
lungs, and he required multiple chest tubes to treat pneumothoraces. Clearly he
was about to die. The only possible hope for him was a lung transplant, but at
this time lung transplantation was not an established operation. It had been done
experimentally by only a few people, one of whom was Frank Veith in New
York City.
Bill decided that we had to attempt this last-ditch maneuver, so after
talking to the family and getting their consent, we launched into a multi-pronged
effort. First, we had to scour the Bay Area for a donor. We were able to locate a
young woman in Vallejo who was brain dead. We had to get a City ambulance
and a team to go there, get permission from her family, and bring her back to
SFGH.
Bill, meanwhile, had contacted Frank Veith and had him flying out to
San Francisco. All parties came together about 10 PM that night. The major
problem we faced initially was that the patient could not survive, even for a
minute, off ECMO. Somehow we had to get him moved to the OR from the
ICU. After scrambling around with the hospital engineers, we came up with a
combination of extension cords totaling about 300 feet. We plugged the cords
into a socket midway between the Ward 12 ICU beds and the large west corner
operating room. The pump was switched over to the extension cord and we
began a slow procession from the ICU to the OR, pushing the bed and pump
together until we could get the boy onto the OR table.
Bill operated in one room and Art Thomas in the other, with Veith
assisting back and forth in both. Fortunately, everything worked perfectly and
the operation—a unilateral lung transplantation—was completed without
incident. The boy improved transiently, but five to six days later, he developed a
bronchial leak, which was followed by sepsis. The donor lung began to swell,
and he became hard to ventilate. We removed the chest sutures to allow the lung
to expand in a desperate attempt to save him, but ultimately nothing worked, and
he died in spite of everything. Overall, it was one of the most heroic attempts to
save someone I ever saw.
The Friday afternoon parties were a tradition, and no one gave much
thought to the City/County rules prohibiting alcohol on the hospital premises. It
was the interns’ job to get the beer up to the “320 Club” in the time for the party.
Normally they understood this was to be done by one of the back stairways. On
one particular Friday, a naïve and newly recruited intern, instead, walked
directly in the front door of the administration building with a case of beer on
his shoulder and proceeded up the main stairs. The nurses helping him were
Donna D'Acuti and Phyllis Harding.
Somehow, one of the hospital police either observed the whole thing or
was called, and he proceeded to arrest the three of them. Bill was called, but this
apparently was not the first such incident and the resolution took awhile. It was
not clear initially what the appropriate punishment would be. In the course of the
whole affair, it was decided that a general movement to raise bail money would
be needed, and someone went out and printed up a thousand or so large lapel
pins with the message, “Free the Mission iii.” As I recall, these sold for a dollar
each, and they are now collector's items. The whole thing went on for two or
141
three weeks and created a great show for everyone. Ultimately, the only thing
sacrificed was the beer.
Jack McAninch recalls…
I vividly recall my very first meeting with Bill Blaisdell in 1977. I was
a young urologist being recruited to become the chief of Urology at San
Francisco General Hospital. There had not been an active on-site Urology chief
at San Francisco General Hospital, even though there were three residents
rotating to the facility at the time. Dr. Blaisdell set a rather stern tone—his usual
demeanor in many circumstances, especially for young faculty. He made me
aware that there had never been an on-site clinical service chief in the
Department of Urology at San Francisco General Hospital and wanted to know
exactly what my plans were and how I expected to run the service.
I had come from a military residency and background and I was clearly
able to comprehend that Dr. Blaisdell was the general in charge. This did not
intimidate me, as it was part of the usual experiences in my background. I
explained to Dr. Blaisdell that one of my major interests was urological trauma
and that I wished to be a very active member of the trauma team. He explained
that his faculty were very experienced in dealing with urologic trauma, and it
was not likely that I would be needed as a member of the team. However, he did
acknowledge that, if I would be willing to attend all urologic trauma injuries, I
would be allowed to participate.
I quickly agreed to attend on all trauma, night or day, that involved the
urinary or genital system. He and I then struck an agreement: On one hand, if I
did not attend when called, then I would not be allowed to participate. On the
other hand, if I was always available and was not called by the Trauma Service
on urological injuries, I was to so notify him. So, early on in my experience I
was in Blaisdell’s office on several occasions complaining about Trunkey,
Lewis, Sheldon, or Lim’s not fulfilling the agreement. Immediately, Blaisdell
made his team aware of my availability and his wishes that I participate to the
full extent. After a few months, I was accepted by the surgical faculty and
became close friends with all of them.
Blaisdell was unwavering in his support of me and continued that
support throughout the time that he was at San Francisco General Hospital. He
quickly included me in all of the faculty meetings, which were held every
Monday morning, and he expected me to give a brief report and bring up any
issues that might exist. This opportunity allowed me to discuss and emphasize
my interest in urological trauma, which proved to be a great benefit in
establishing myself as a urological trauma person with the group.
Over the next two to three years, I was included in all the social events
of the Department of Surgery and was looked upon as a general surgeon who did
urological work. This attitude still continues today. Blaisdell was the principal
person responsible for developing the initial relationship with Urology and for
allowing me to participate heavily in the Trauma Service during his time. His
help and guidance provided me with wonderful research opportunities. He was
always available to give his quick and candid opinions of research projects, but,
more importantly, he was thoughtful and supportive of all my efforts. He never
asked a person to perform any type of research or clinical activity that he
himself was not willing to perform. He was a unique and wonderful teacher and
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a great inspiration to me as a young faculty member beginning an academic
career.
It should be added that Jack was the single parent for four young boys,
but this never seemed to handicap him in any way in his provision of
outstanding care of SFGH urological patients
Brent Eastman recalls…
When a resident at SFGH, I was making rounds with Dr. Blaisdell and
the team on Christmas Eve, 1971. I had just left the bedside of a patient who was
status post thoracotomy for a gunshot wound (GSW) of the chest, when the
patient asked me to come back to the bedside. He requested that the chest tube
be removed. I said “no,” as Blaisdell had stated that we needed to verify there
was no air leak before clamping and then removing it.
The patient then explained to me that he had to get out of the hospital
that night—Christmas Eve—so he could meet a friend who worked at one of the
large department stores. His friend was going to “make a bicycle available” out
the back door. The patient explained that his 10-year-old son wanted a bicycle
for Christmas more than anything else in the world, and this was the only
possible way that he could get him one. I made the decision, without consulting
Blaisdell, to clamp the chest tube and give the patient a few hours “temporary
leave of absence.” He left with the tube clamped and safely returned later that
night, mission accomplished—sort of the “Spirit of Christmas!” On rounds
several days later, Dr. Blaisdell opined that we could now safely clamp the chest
tube. I had thought perhaps I should report this incident at the next Saturday
Death & Complications (D&C) Conference, but I wasn’t sure how to classify
the incident.
As chief resident in 1972, I had worked up a vascular patient at SFGH
who had an abdominal aortic aneurysm—a great elective case! The day of
surgery arrived, when I was to repair the aneurysm. Bobby Lim was my
consultant. He advised me to make very early rounds in the Mission before Dr.
Blaisdell’s notorious pre-dawn rounds, so that we could do the case knowing we
had no emergencies pending. I was just beginning the retroperitoneal dissection
when Blaisdell came into the operating room and asked me about the woman in
Bed 3 in the female ward in Mission Emergency Hospital. I was so pleased that I
had made pre-Blaisdell 5 AM rounds, had examined her, and was able to report
to him that she was being admitted to the Gynecology Service with the diagnosis
pelvic inflammatory disease (PID). He informed me that he had also examined
her and thought she had appendicitis. This was chilling because Blaisdell was
rarely if ever wrong about a clinical diagnosis.
He gave me the choice of scrubbing out of the aneurysm case and
operating on her or he would operate on her himself. I was doomed if she had
appendicitis and I didn’t operate on her, but it was my first aneurysm. What to
do?
Bobby Lim quietly asked me if I was pretty sure about my diagnosis of
PID, and if I was, he suggested that I proceed with doing the aneurysm. I was,
and Blaisdell operated on the young woman. A while later he came back into the
operating room, where we were well underway with the aneurysm repair. With
great trepidation, I asked what he had found. He replied, “PID,” but she could
have had appendicitis, and he hoped I had learned a lesson. I knew I had—I just
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wasn’t sure what. However, one thing I did learn in those years at the SFGH: Dr.
Blaisdell is the most brilliant diagnostician of anyone I have known in my
medical career. Fortunately for me, this case of PID was a rare exception.
Those days as a resident at the SFGH with Blaisdell and his staff
remain perhaps the most wonderful experience of my surgical career. It was
Blaisdell who first taught me that the most fundamental principle of patient care
is: “Always put the patient first” —and, as in this case, I try to do just that.
Among Eastman’s achievements are being named clinical professor at
UC San Diego and chief of Trauma at Scripps Hospital System, San Diego, as
well as chair of the Committee on Trauma of the American College of Surgeons
and Regent of the American College of Surgeons.
Thomas Russell recalls…
My most vivid memory was an event that happened on a Saturday night
in May 1975. I was chief resident on the Trauma Service, and it was a very
active night with all sorts of gunshot wounds and stab wounds. Our team was
working in several rooms and was successful in getting through a very difficult
and tiring night. Clearly, we had been working well beyond the 80-hour work
week. The patients were all in various states of recovery, until one of the ten or
fifteen patients that we had operated on that Saturday night had some mild
abdominal pain. A flat plate xray of the abdomen was obtained by the intern that
showed not only a retained clamp, but without a doubt the largest clamp that
could have possibly been on the Mayo stand the night of surgery! How it was
left in the abdomen was beyond me! I immediately confiscated the xray and told
the team that I would take care of it.
With great trepidation and forethought, I went into Dr. Blaisdell's office
thinking that this was the end of my experience as a resident. I explained to him
about the operation and then without mentioning the clamp, told him that the
patient was doing quite well. I then showed him the xray thinking that this was
the end. I held on to the table expecting the very worst news.
After he looked at the film Blaisdell started smiling and laughing,
which baffled me a great deal. I was expecting a verbal tirade. The only words
out of his mouth were, “I guess you know what to do next.” That clamp was
removed immediately. I learned that, when Blaisdell has confidence in you, even
a situation like that could have a good outcome.
My other long-lasting memory is: after finishing residency, I went into
private practice and worked frequently at the Pacific Medical Center, the site of
the old Stanford Hospital. Norman Thompson—Muriel Steele’s husband, who
was a severe pulmonary cripple—was a patient there. He had undergone surgery
for diverticulitis done by one of my partners and was not doing well. Muriel had
asked Bill to see her husband. Bill, unbeknownst to all of us, made rounds that
night and did a rectal exam on Norm—bear in mind that this was before the days
of the CT scan. I was covering for my partner, and I received an urgent call from
Dr. Blaisdell via the exchange. He had just completed a rectal exam and was
convinced that Norm had a pelvic abscess. He felt that we should operate
immediately and drain the abscess. I thought to myself that I had gone through
this long residency, which lasted more than ten years, and never had such an
interaction with Dr. Blaisdell. I immediately called my partner, who refused to
re-operate on the patient. Norm went on to recover without drainage of the
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infection. These were wonderful years. The last story points out that Dr.
Blaisdell never goes away—we will never miss him because he is omnipresent.
Russell has been chief of Surgery at Presbyterian Hospital in San
Francisco, president of the Pacific Coast Surgical Association, and is now
executive director of the American College of Surgeons.
Norman Christensen recalls…
Shortly after Blaisdell became chief, he started the “visiting professor”
program, in which a former chief resident would come to SFGH, live in the
chief resident’s quarters and attend on the Trauma Service for a week. I am not
sure how long the program lasted after Blaisdell left, but after I had a taste of it,
I thought it was the best method for continuing education that I had ever seen! I
determined to continue it, if possible, and prevailed on Bill to let me return year
after year for at least two weeks. Later, I did the same under Trunkey and Lewis.
One year, I spent two months at SFGH. These periods of acting
attending almost always occurred during the summer, when many of the faculty
were taking vacation. If Blaisdell was home, there were tennis games on
Saturday after rounds in the courts behind his house, with residents and faculty
like myself. When the weather was warm, a beer after the games was part of the
day.
The dynamism of the Surgical Service at that time was almost palpable.
The staff were young and vibrant, excited by trauma care and bent on making
real advances in the understanding and management of injury. Over the years, I
was exposed to outstanding faculty members who were making names for
themselves in American Surgery. I also met a seemingly endless stream of
talented surgical residents who would become influential in their field in time.
For years it has been a great pleasure to see these former residents at surgical
meetings.
My surgical life was broadened immeasurably by continuing to visit
SFGH as an attending on a yearly basis. I was able to write a few clinical papers
with residents, and my experience at SFGH led me into the Pacific Coast
Surgical Association and the Western Surgical Society, and gave me other
career opportunities.
Although Christensen was primarily in private surgical practice in
Eureka, California, his contributions to Surgery were unique. He was a clinical
professor of Surgery at both Stanford and UCSF. He was also a Governor of the
American College of Surgeons and President of the Pacific Coast Surgical
Association, the Northern California Chapter of the American College of
Surgeons, the Northwest Medical Association, and the Stanford Alumni
Association.
George Sheldon recalls…
The residents revered Bill Blaisdell, but they all were leery of his
unannounced appearance in the OR and on the wards. As one of the residents
put it, “you could get “green inked.”
The Johns Hopkins approach of closed-chest massage for cardiac arrest
had been adopted for all resuscitations. This “code blue practice” required the
surgery resident to appear at resuscitation and do chest compression. This was
145
usually a futile and unpleasant exercise. In 1968, when I was a senior resident, I
was called to Mission Emergency one night—there was a man there who had
been robbed and shot in the chest. Finding that the patient had cardiac arrest, I
did a left thoracotomy and found a wound to the right ventricle and the right
pulmonary artery. I decompressed the cardiac tamponade and repaired the
injuries. The patient survived! Blaisdell reviewed the situation and concurred
with my conclusions about the futility of closed resuscitation for hypovolemic
patients. Open-chest resuscitation was adopted as the standard practice for
trauma resuscitation at SFGH, and this subsequently became standard practice
everywhere.
Following this encouragement, I was fortunate to do five successful
open-chest heart resuscitations during that rotation. One notable one occurred at
noon on a Saturday when I was on call. Blaisdell and I were having coffee in the
cafeteria when I was called to Mission Emergency. Before I went, I asked
Blaisdell if he would stay until I checked the case out. The patient was a drug
addict who had a self-inflicted chest wound and seemed to be evolving into
pericardial tamponade. I called Blaisdell in the cafeteria to tell him I was taking
the patient to the OR and asked him to meet me there. Unfortunately, the patient
arrested in the small elevator leading from the emergency room to the OR, but I
managed to do a thoracotomy in the elevator. Bill arrived at the OR just as the
elevator door opened and saw my hand in the chest. Characteristically, he did
what needed to be done. This was an emergency cut-down for venous access.
During the senior part of my residency from 1968-1969, Blaisdell mostly
covered the Trauma Service single handedly.
While at the Brigham, I had told Dr. Francis Moore of Blaisdell’s work
with acute respiratory distress syndrome (ARDS), and Bill was invited to be a
visiting professor at the Brigham. He reaffirmed that I had a job at the County
when I finished my fellowship. The next year, we met at the Society of
University Surgeons in Pittsburgh. I was ready to give up on research, but he
persuaded me to stay the course.
Typically, on our return to California, Bill and Marilyn Blaisdell
invited our family—three kids, one dog, and two adults—to stay in their home.
Our furniture was actually stored in their basement for several months.
My role was Project Coordinator for the Trauma Center Program
Project Grant. Bill gave me carte blanche to run the program with his continued
oversight. The grant added luster to the SFGH and the department. In 1973, we
received one of the first 18 National Research Service Award (NRSA) Training
Grants, which paid for a fellow in my laboratory. The first fellow was Richard
Sanders, who was followed by a number of outstanding fellows, many of whom
are currently academicians.
Blaisdell insisted that student teaching must be a high priority. In fact,
the comments students made about our individual teaching sessions were
circulated and we all competed for their favor.
Bill exemplified a type of mentoring and faculty support that
transcended expectations. He was always more excited about his faculty’s
having a paper accepted or gaining membership in an organization than any
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accomplishment of his own. He wanted us to have outstanding opportunities and
be recognized in our own right. Blaisdell had career aspirations for all of us. My
assignment included the title of chief of the Trauma Service—which was
generous, as we all were chiefs during our time on call. Blaisdell advocated so
strongly for us that sometimes we felt we were not up to his standards or
expectations. Perhaps his only fault as a leader was that he seldom could believe
anything unfavorable about his faculty.
The period was really one of a Camelot, and we all wished it would
never end. However, Camelot, and all good things, do come to an end. Bill was
initially reluctant to interview for the chair of Surgery at UC Davis, but he
returned with the observation that there was more there than he expected. For
Bill, it was ideal. He would have been suffocated in a department or situation
without problems to solve. Surgery at UC Davis—like SFGH when he arrived
there—was a problem department and provided him with an appropriate
challenge for the remainder of his academic life.
BLAISDELL’S
BLAISDELL’S 1978
1978 FACULTY
FACULTY
Lewis, Sheldon, Steele, Trunkey,
Trunkey, Blaisdell,
Blaisdell, Thomas,
Thomas, Lim
Lim
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CHIEF RESIDENTS — 1966-1978
1966-1967
Steve Cary
Bob Edwards
Paul Kelly
Ole Peloso
Al Tassi
Larry Way
1967-1968
Gil Ashor
Peter Braunstein
John Bull
Lou Buscaglia
Charles Jenkins
Harry Wanebo
1968-1969
Bob Allen
Serge Betencourt
Larry Cohn
George Sheldon
Peter Volpe
Jay Zubrin
Al Hocker
1969-1970
Treat Cafferata
George Husband
James Morrison
Charles Rosson
Bob Stallone
RoyTawes
1970-1971
Jan Bossart
Dave Fromm
Jeff Nunes
Tom Reed
Ted Schrock
Donald Trunkey
Richard Geist
1971-1972
Brent Eastman
Jerry Goldstone
Frank Lewis
Dave Oliver
Tom Shapiro
Slate Wilson
John Snyder
Stuart Gourlay
1972-1973
Orlo Clark
Doug Dorner
Dave Fraser
John Mehigan
Ralph Roan
John West
James Yee
Jerry Sydorak
1973-1974
Tom Gadaz
Barry Gardiner
John Knudsen
Rich Margules
Neil Olcott
Francis Owings
Ed Conley
John Young
1974-1975
Bob Bush
Roy Carlson
Carol Raviola
Walt Rohlfing
Tom Russell
Bob Swanson
Pat Dietz
1975-1976
Bob Demling
Cliff Deveney
Jim Holcroft
Fred Litooy
Rich Starrett
Pat Twomey
1976-1977
Earl Baumgartel
Dennis Flora
Jim Malone
Peter Noyes
Sid Schwab
Dave Tapper
1977-1978
John Boey
Ron Clark
Karen Deveney
Dave Hohn
Tony Roon
Jim Wilson
148
SENIOR SFGH FELLOWS
Postgraduate Fellows
(Residency training institution listed in parentheses)
Bengt Zederfeldt 1966-1967 — Wound healing with Hunt (University of
Gothenburg) Professor, University of Malmo
Bruce Conolly 1967-1968 — Trauma and Hand with Blaisdell and Kilgore
(University of Sydney) Professor, Sydney University
Lou Buscaglia 1968-1969 — Vascular with Blaisdell (UCSF)
Peter Braunstein 1969-1970 — Vascular with Blaisdell (UCSF)
Thomas Maxwell 1970-1971 — Vascular with Blaisdell (University of British
Columbia) Professor, University of British Columbia
Robert Allen 1971-1972 — Trauma with Blaisdell (UCSF) Professor, UCSF
R. Bruce Heppenstall 1971-1972 — Wound healing with Hunt and Sheldon
(University of Pennsylvania) Professor of Orthopedics, University of
Pennsylvania
Nils Darle 1972-1973 — Trauma with Lim (University of Gothenburg)
Hoon Sang Chi 1974-1975 — Nutrition with Sheldon (Seoul University)
Director, Yonsei University Medical Center, Seoul, Korea
Michael Nerlich 1976-1977 — Nutrition with Sheldon (University of Hanover,
Germany
Louis Oppenheimer 1977-1978 — Respiratory Failure with Lewis, Professor of
Surgery, (University of Winnipeg)
John Sturm 1977-1978 — Respiratory failure with Lewis, Professor of Surgery
(University of Hanover, Germany)
Sergei Pilduski 1972-1973 — Trauma with Blaisdell (University of Krakow,
Poland)
Steve Parks 1976-1977 — Shock with Trunkey, Clinical Professor of Surgery
(UCSF Fresno)
David Effeney 1976-1977 — Coagulation with Blaisdell, (Professor, then Dean
University of Queensland, Brisbane, Australia)
Frank Lewis 1974-1976 — ECMO with Thomas (UCSF)
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JUNIOR FELLOWS
UCSF Research Fellows
Bob Stallone 1967-1968 — Pulmonary physiology with Blaisdell
Treat Cafferata 1967-1968 — Intravascular coagulation with Blaisdell (Clinical
Professor of Surgery, University of Nevada)
Joseph Okimoto 1968-1969 — Wound healing with Hunt
Jeff Nunes 1968-1969 — Intravascular coagulation with Blaisdell
Tim String 1969-1970 — Intravascular coagulation with Blaisdell (Professor of
Surgery, University of Alabama)
Neil Olcott 1970-1971 — Intravascular coagulation with Blaisdell (Asst
Professor of Surgery UCSF, Clinical Professor Surgery, Stanford)
Richard Sanders 1976-1977 — Nutrition with George Sheldon, Clinical
Professor (University of Louisville)
Fred Litooy 1972-1973 — Wound healing with Hunt & Sheldon (Professor of
Surgery (Loyola University)
James Holcroft 1974-1975 — Shock with Lim and Trunkey (Professor of
Surgery UC Davis)
Sharon McLaughlin 1975-1976 — Trauma with Lim
Kenneth McIntyre 1977-1978 — Coagulation with Lim and Blaisdell, Professor
of Surgery (University of Arizona)
Scott Petersen 1977-1978 — Nutrition with Sheldon , Clinical Professor (Univ
Arizona)
Jim Raffa 1977-1978 — Shock with Trunkey
Richard Sanders 1973-1974 — Nutrition with Sheldon
Kenneth Kudsk 1974-1975 — Nutrition with Sheldon, Professor of Surgery
University of Tennessee
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CHAPTER IV
THE TRUNKEY YEARS: 1978–1986
In 1977, Bill Blaisdell, the chief of Surgery at SFGH, decided that it
was time to leave. Paul Ebert had taken over the chair of Surgery at UCSF,
replacing Bert Dunphy, and things were not going to be the same. Blaisdell felt
that the most productive members of the faculty were at San Francisco General,
but it was clear that any resources available would go toward building at the
Parnassus campus, not San Francisco General. He felt his career was plateauing
and that the young bucks in his department were nipping at his heels.
On July 1, 1978, he accepted the job of chief of Surgery at UC Davis.
Paul Ebert indicated that he wished to appoint Blaisdell’s successor from within
the UCSF faculty and asked Blaisdell’s advice. The obvious candidates were
George Sheldon and Don Trunkey. Blaisdell refused to be drawn out as to who
would make the best chief. His judgment was, “Either would be superb. Both are
sure to have their own departments one day.”
After much head scratching and vacillating, Ebert selected Trunkey as
chief. Blaisdell felt that this was because he wanted to keep both Trunkey and
Sheldon. He felt that Trunkey might leave immediately for another job and that
Sheldon, who was deeply involved in research, was more likely to stay for a
while—and this did prove to be true.
In 1978, the hospital was at its apogee. The new San Francisco General
Hospital was but two years old. The Trauma Program was receiving both local
and national acclaim, thanks to the activities of its productive staff. The City
coffers were filled, and the hospital was well supported financially. Thanks to
the publicity its Trauma Program was receiving, the director of Public Health
was successful in promoting funding for the ambulance system and for SFGH's
Medical and Pediatric Services with the argument that they were needed to
support the Trauma Program. While the general public did not necessarily want
to look to SFGH for their medical care, the publicity being received by the
hospital was such that they believed that SFGH was where they wanted to go if
they were injured.
An outstanding hospital administrator, Charles Windsor, had been
appointed in 1976 and was providing strong leadership for the hospital, which
had suffered from generations of weak or ineffective managers.
However, there was a dark cloud that would obscure this bright picture
almost immediately and make Trunkey’s job more difficult. In June of 1978,
Proposition 13—an initiative placed on the ballot by public petition, which is a
tradition of California’s constitutional system—was passed by the irate
taxpayers of California, who were suffering from what seemed to them to be an
unacceptable burden related to rapidly escalating property taxes. Property taxes
were the main source of the City’s revenue, and overnight Proposition 13 cut
this revenue drastically. Within a few months of the onset of Trunkey's tenure as
chief of Surgery, the hospital was threatened with closure.
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At that time, Trunkey had just visited Australia, where he served as the
Douglas Lecturer. On his return, he had planned to stop off for a few days in Fiji
for a rest, but he received a call from the hospital administrator asking for his
help. He cancelled the rest of his trip and returned to assist in the defense of the
hospital. This effort was successful—the hospital remained open, but with a
drastic reduction in its budget.
Matters were not helped by the presence of a virulent City chief
administrative officer (CAO), Roger Boas. Boas had run an automobile
dealership before being appointed CAO in 1976. The Department of Public
Health, the hospital, and all health facilities receiving funding from the City of
San Francisco fell under the authority of his office. He had no knowledge of
hospitals and no feeling whatsoever for the issues regarding provision of health
care. He believed that the private sector could handle indigent care and when his
proposal to close the hospital was rejected by the political system, he ordered
specific cuts, such as those related to blood utilization, xray films, and pharmacy
expenditures. SFGH administrator Charles Windsor pleaded to be allowed to
handle the cuts so as to do the least damage. When his request was denied, he
resigned. His resignation was followed by a revolving door of acting and semipermanent hospital administrators—a total of five during Trunkey's eight years
as surgical chief. Fortunately for the morale of the staff, Trunkey was able to
bear this frustration with his usual equanimity.
The principal impact on the Surgical Service was the requirement to cut
back drastically on elective surgery. Since Trauma was the sacred cow and no
other hospital would take trauma cases, this and related services were financially
spared. Therefore, the emergency room, xray department, and laboratory
survived more or less intact.
THE PROFESSOR
Donald D. Trunkey
Donald
Trunkey—a
tall,
affable,
charismatic
man—was
appointed chief of Surgery in the fall of
1978, at the age of 41.
Trunkey had grown up in a
small town 50 miles south of Spokane,
Washington. He was the son of a
college-educated teacher who became a
blacksmith in order to earn a living
during the depression. As a teenager,
he drove wheat trucks, tractors, and
combines. While in college at
Washington State University, he
supported himself by working as a
construction worker, miner, service
station attendant, and carpenter.
Trunkey graduated from college in 1959, marrying Jane Mary Henry in
his senior year. Jane’s straightforward, open, and unadorned enthusiasm for life
152
has been a delightful complement to Don’s commanding presence—theirs is a
relationship that remains strong as it approaches half a century.
He matriculated at the University of Washington School of Medicine in
the fall of 1959 and worked in Al Shears’s cardiac electrophysiology laboratory
during his first year. He participated in an epidemiological study of the
Coxsackie virus in his second year of medical school. His initial goal was to
become a small-town general practitioner in Eastern Washington. His main role
models as a medical student were two distinguished Internists, Dr. Robert G.
Petersdorf and Dr. Clement A. Finch. Bob Petersdorf served as chair of the
University of Washington Department of Medicine from 1964 to 1979 and
president of the Association of American Medical Colleges from 1986 to 1994.
Clem Finch—a gifted teacher and eminent hematologist—established the
Division of Hematology at the University of Washington.
After his graduation from medical school in 1963, Trunkey began a
rotating internship at the University of Oregon. There, he came under the spell
of Bert Dunphy, the chair of Surgery and, by the third week of his Surgery
rotation, the future course of his professional life was decided.
However, Uncle Sam had other plans for Trunkey. He was drafted into
the Army and was sent to Germany after he completed his internship in June
1964. Alcoholism was rampant in the professional Army at that time. He was
profoundly affected by the devastating effects of alcohol addiction on the lives
of his patients, and set up an Alcoholics Anonymous Club to help them with
their burden.
He maintained his relationship with Dunphy and in May 1966, while on
vacation in Norway, he received a phone call offering him a residency position
in Dunphy’s new Department of Surgery at the University of California, San
Francisco (UCSF). By the time he returned to the United States, he had
tentatively opted to pursue a career in ophthalmology—a decision influenced by
his father-in-law, who was a leading ophthalmologist in Colfax, Washington.
But he ultimately chose to accept Dunphy’s offer at UCSF.
Trunkey recalls his residency at UCSF as “a perfect time.” He was
influenced by Bert Dunphy, Jack Wylie—chief of Vascular Surgery, Maurice
Galante, Leon Goldman, and of course Bill Blaisdell. His first rotation was at
San Francisco General Hospital. He had been there only a few weeks when
Blaisdell called him into his office and asked, “What is this I hear about your
wanting to go into ophthalmology? That is a grave mistake.” Don must have
been having second thoughts about such a career, as he acknowledged that
perhaps he was better suited for a career in surgery. He was particularly
attracted to the “instant gratification” of trauma surgery that he was seeing at the
General. Gunshot wounds and soft-tissue infections were epidemic, thanks to the
escalating use of drugs and the associated violence that was occurring in the
City during his residency.
His first rotation at SFGH during his chief residency was to the
Elective Surgery Service in November 1970. At that time, there was an Elective
Surgery Service; a Trauma Service that did both trauma and emergency surgery;
and an Extremity Service, run by a junior resident, that treated the myriad
patients with soft-tissue infections. His next rotation that year was two months
on the Trauma Service. During his third week on the Service, he invited Bert
Dunphy to serve as his visiting professor, and Dunphy—because of his
admiration for Don—agreed to serve (see Chapter III).
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During his chief residency, Trunkey made the decision to pursue a
career in academic surgery as opposed to private practice. His interest in trauma
was solidified by his experience at SFGH and, encouraged by Blaisdell, he
consulted with Dunphy. During his interview, he told Dunphy that he would like
to spend a year with Tom Shires, chief of Surgery at Parkland Memorial
Hospital in Dallas, Texas, with the University of Texas Southwestern Medical
School. Shires had edited a major book entitled Care of the Trauma Patient.
Parkland was a legendary hospital because of its association with the treatment
of President Kennedy when he was assassinated. Many members of the surgical
and nursing staff there had participated in the treatment of Kennedy and
Governor John Connolly. Also there was a basic science research program
focusing on shock. It seemed the perfect place for additional training in Trauma.
Dunphy immediately picked up the phone, called Shires, and arranged the
fellowship for him.
Trunkey had a very productive year in Dallas with Tom Shires, whose
research centered on the study of the cell in shock. He learned to measure cell
transmembrane potential, which permitted the calculation of electrolyte and
water movement in and out of the cell. He would continue to utilize this
technique to study fluid resuscitation in shock when he established his own
laboratory back in San Francisco. During this period, he wrote important articles
on the management of rectal trauma and liver trauma, which were published
after his return to San Francisco.
He polished his clinical skills by taking call on the Parkland Trauma
Service. The clinical approach, Trunkey recalls, was quite different at Parkland.
All surgical problems were managed by protocols approved by the chief—
Dr. Shires. Any deviation from the protocol, regardless of the rationale, resulted
in a harsh rebuke. (Editor’s note: It is hard to imagine Trunkey following
protocols!)
During his tenure in Dallas, Trunkey received a number of phone calls
from Blaisdell encouraging him to return to SFGH. The problem was that he
knew George Sheldon had joined the faculty just as he had left for Texas. The
issue was, “Is there room for both of us?” Ultimately, he was convinced that
there was, primarily because the SFGH Surgery Department had just received a
large Program Project Grant that would ensure funding for his research.
Trunkey returned to San Francisco General in the summer of 1972 and
began his academic career by continuing his study of cellular transmembrane
potentials in primates subjected to shock. This work was funded by an NIH
grant of $60,000 per year, which allowed him to hire Mary Ann Carpenter as his
research technician. By 1978, his research focused on transmembrane potentials
in the adrenal gland and the liver, the effect of steroids on the response to shock,
and the study of transmembrane calcium transport, both in the animal laboratory
and in ICU patients.
Between 1972 and 1978, Trunkey published 32 articles, primarily in
the fields of clinical trauma care and the pathophysiology of shock. Jim
Holcroft, an outstanding resident, was an important collaborator in the
laboratory investigations of the physiological and cellular effects of fluid
resuscitation. Holcroft, while Trunkey’s research fellow, developed a method of
calculating extravascular lung water.
During his time in Texas, Trunkey had been exposed to Charles Baxter
and the Burn Center at Parkland Hospital. SFGH had no organized burn unit,
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and burns were cared for on the regular hospital wards. Most burns in the City
were treated at the private burn unit run by plastic surgeons at St. Francis
Hospital. The quality of care provided for the burn patients in San Francisco did
not compare with that provided at Parkland. Shortly after Trunkey’s return, he
approached Blaisdell and offered to establish a burn unit. Blaisdell thought it
was an excellent idea and it was carried out in typical Trunkey style, leaving
hospital administration apoplectic! (See Chapter III.)
Trunkey was a superb teacher, receiving the UCSF Academic Senate
Teacher of the Year Award in 1975 after only three years on the faculty. He
loved to shock people and make outlandish statements to see their effect.
Whenever Trunkey sat on a panel at a national meeting, it was great theatre and
the hall was packed. “He made a huge impression, and his persona was bigger
than life. It gave him an entrée into every level of medicine. He was
immediately in charge no matter where he went.”
He was a superb technical surgeon. He was fast but precise at the
operating table. His compassion for both his patients and his colleagues, his
passion for his work, and his sound surgical judgment outshone even his
technical virtuosity. His skill and supreme self-confidence gave him a pleasing
way of putting the operating room team at ease. With a glance, he could
communicate to his team the probability of the patient’s survival.
By the time Trunkey assumed the position of chief of Surgery at
SFGH, he had become an international celebrity in the world of trauma surgery.
The study by West, Trunkey, and Lim, done the year before he became chief of
Surgery, was having its full national impact and precipitated attention directed at
establishing trauma programs everywhere. Trunkey’s fame resulted not only
from his charisma, but also from his devotion and untiring advocacy of the
importance of organized systems of trauma care in reducing morbidity and
mortality.
Trunkey succeeded Blaisdell as chair of the Northern California
Chapter of the Committee on Trauma of the American College of Surgeons in
1979. From there he was appointed to the American College of Surgeons
Committee on Trauma (COT) and served as chair of that Committee from 19821986. During that period, he stimulated the certification and verification of
trauma programs. During Trunkey’s tenure as chair, the COT initiated the
Advanced Trauma Life Support (ATLS) program to train surgeons and
emergency physicians in resuscitation techniques appropriate for trauma. In
1983, as a result of a discussion between UCSF Dean Julius Krevans and the
editor of Scientific American, Trunkey received an invitation to write a review
article on the subject of trauma. This article popularized the concept of trauma
as an epidemic. Trunkey put trauma on the national agenda and made the need
to improve trauma care understandable. There can be no question but that
Trunkey was the father of organized trauma care in the United States.
In the course of promoting the importance of trauma care, Trunkey
became a world traveler—lecturing and participating on panels in postgraduate
courses and in visiting professorships. Despite spending extensive time away
from SFGH, he immediately dug in on his return, and during the course of the
academic year he managed to take his full share of trauma and emergency call.
How he managed his demanding schedule was amazing to behold!
In 1980, Trunkey became a director of the American Board of Surgery,
and he chaired its Committee on Vascular Surgery the following year. In 1981,
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he was elected President of the Society of University Surgeons. The same year
he received the James IV Surgical Traveling Scholarship. He used these
positions as a bully pulpit to push the Trauma agenda within both the
professional and political arenas. In 1983, he was appointed to the NASA
advisory committee, and he had ambitions to take some of his shock and trauma
concepts into space. In 1986, Trunkey became the President of the American
Association for the Surgery of Trauma.
SURGICAL STAFF
When Trunkey took over as chief of Surgery at SFGH, the full-time
faculty members included Art Thomas, Bob Lim, George Sheldon, Muriel
Steele, and Frank Lewis.
Muriel Steele
Muriel Steele did an exceptional job of coordinating the outpatient
Surgery Services, supervised the department’s billing and finances, ran the
Proctology Clinic, and did most of the breast, endocrine, and anorectal surgery
(for Steele’s biography, see Chapter III). Her Colorectal Clinic had so many
gay patients with perianal warts that the residents referred to it as “Wart Clinic.”
This was before AIDS was recognized. Steele found that many of her patients
had unusual infections, but she could not get the Medical Service interested in
them.
She also served as the conscience of the department, making sure that
everyone kept their clinical assignments, met their teaching schedules, and
covered their clinics. She was the only member of the faculty who could
intimidate Trunkey.
She served two terms as chief of staff and, more than any other person,
helped ensure that the hospital met JCAH guidelines.
Unfortunately, Steele developed leiomyosarcoma of the uterus in the
fall of 1978 and battled the disease heroically during 1978-1979. She developed
a malignant bowel obstruction in the fall of 1979. Trunkey operated upon her
and performed an intestinal bypass of the unresectable tumor. She died at home
shortly thereafter, receiving hospice care from her long-time colleague and
friend, Sandy Libby. Libby was the head nurse in the Surgery Clinic located on
Ward 3M.
Shortly after her death, in recognition of her contributions to the
hospital and, in particular, her development of SFGH’s Medical and Surgical
Clinics, the Surgical Clinic was renamed the Muriel Steele Surgery Outpatient
Clinic.
Robert C. Lim, Jr.
Bob Lim was the mainstay of the clinical service, and he did most of
the vascular surgery and all of the liver surgery (for Lim’s biography, see
Chapter III). Fluent in Cantonese and a product of San Francisco’s Chinatown,
Bob maintained a close relationship with the physicians serving the Chinese
community. His superb judgment, technical virtuosity, and pleasing bedside
manner made him a favorite with the patients and their families, the referring
physicians, and the residents. He did most of the endocrine surgery—the
thyroidectomies, parathyroidectomies, and adrenalectomies. He also took on the
responsibility for providing vascular access for the Nephrology Service. He
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continued to run the Emergency Department until 1982, when he asked to be
relieved of this chore and was replaced by Frank Lewis.
Arthur Thomas
Art Thomas continued to be responsible for thoracic surgery, as well as
taking his share of trauma call with all the others. The residents loved scrubbing
with “Uncle Art.” The chest cases were challenging, and Art’s vast experience
and unique sense of humor added greatly to the residents’ enjoyment of the
operations. (For Thomas’s biography, see Chapter III.)
Frank Lewis
Frank’s special interest was the ICU. He had become interested in the
acute respiratory distress syndrome (ARDS) and initiated a research program
directed at lung water measurement. His detailed biography is provided in the
subsequent chapter. (For Lewis’s biography, see Chapter V.)
George Sheldon
George Sheldon ran the Trauma Program Project Grant and was
actively involved in nutrition research. He supervised a continuous line of
trauma research fellows. In July 1984, after receiving numerous similar offers,
he left to take the chair of Surgery at the University of North Carolina. (For
Sheldon’s biography, see Chapter III.)
Richard Crass
Rich Crass joined the faculty in July of
1979, on the completion of his chief residency at
UCSF. He was Trunkey’s first recruit and served as a
replacement for the loss of Muriel Steele. Crass was
a mustached, cigar-smoking, natty dresser with a dry
sense of humor. He had an encyclopedic knowledge
of the literature of gastrointestinal surgery. He had
done a fellowship in gastrointestinal (GI) surgery at
the Beth Israel Hospital in Boston in the middle of
his residency. Trunkey was interested in the
possibility that gut permeability was a mediator of
sepsis, and he had hoped that Rich would set up a laboratory to study this
problem. However, Rich’s interests proved to be primarily clinical, and he
developed a close working relationship with John Cello—the chief of GI
Medicine at SFGH. During this period, he made many important clinical
contributions related to the management of gastrointestinal bleeding.
Crass left SFGH to go to the University of Oregon with Trunkey, when
Trunkey left San Francisco. Subsequently, in 2000, he was appointed chair of
Surgery at the University of Florida, Jacksonville.
William Schecter
Bill Schecter has had an extremely interesting and diverse background.
He was born and raised in New York City and spent two summers in an
agricultural high school in Israel and a third summer at a kibbutz.
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At age 16 years, he spent three months with
his father's business agent in Tokyo, Japan, living in
a Japanese household. He graduated magna cum
laude with a degree in political science from Harpur
College in Binghamton, New York. While there, he
studied French, Russian, and Arabic. He obtained his
M.D. degree from Albany Medical College in New
York in 1972 and took a rotating internship at SFGH
the following year. Because of his interest in critical
care, he decided to take a residency in anesthesiology
at Massachusetts General Hospital before starting
surgical training. He completed his anesthesiology
residency in September 1975 and was accepted for surgical residency at UCSF
starting July 1976. However, there were several dropouts from the program, and
Schecter was able to start his training on March 1, 1976.
Schecter was Rich Crass’s chief resident classmate, both finishing
residency in June 1979. He joined the faculty at SFGH in January 1980, after
completing a fellowship in hand surgery with Eugene Kilgore and Bill
Newmeyer. He took a leave of absence from the faculty for three years.
Between 1981 and 1983, he served as Chief of Surgery at the LBJ Tropical
Medical Center in American Samoa. He was a Lecturer in Surgery at the
University of Natal in Durban, South Africa from 1983-1984 where he gained
extensive experience with esophageal and gastric resection for malignancy as
well as tropical surgery and trauma.
He returned to SFGH in 1984 and shared call on the Hand and
Extremity Service with Robert Markison, in addition to participating actively as
a general and trauma surgeon. He became Chief of Surgery at SFGH in 1993,
succeeding Frank Lewis.
Robert Markison
When Bill Schecter left for Samoa in 1981,
Trunkey hired Bob Markison to replace him.
Bob was a brilliant, creative thinker with an
artistic temperament. He played several wind
instruments professionally, was an artist and
sculptor, and used his artistic abilities to
illustrate his lectures and operative notes. After
completing his general surgery residency at
UCSF in 1983, he trained in hand surgery with
Eugene Kilgore and Bill Newmeyer. In
addition to hand surgery, Markison also covered general surgery and trauma.
He was one of the pioneers in the use of computer technology at San Francisco
General. Bob considered his position, “one of the ultimate jobs in surgery.”
Anthony Meyer
Tony Meyer was recruited by Trunkey after completing his residency
in surgery at UCSF in 1982. He was considering a career as a surgical
oncologist, but declined a fellowship at M. D. Anderson Hospital when Trunkey
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asked him to join the SFGH Faculty. He filled two
important roles, serving as both ICU and Burn
attending.
He left in 1984 with George Sheldon to
take the position of ICU and Burn director at the
University of North Carolina.
Meyer went on to become a
national leader in Trauma and Critical Care, and
then the President of the American Association for
Surgery of Trauma. He was appointed chair of the
Department of Surgery at the University of North
Carolina in 2001, following George Sheldon’s
retirement.
Michael Hickey
Mike Hickey was recruited in 1985 to augment the role of the
Department of Surgery in the emergency room and to replace the expertise in
surgical nutrition, which was lost when George Sheldon left. (For Hickey’s
biography, see Chapter V.)
SURGICAL SPECIALTIES
Anesthesia
Barrie Fairley continued as chief of Anesthesia until 1979, when he
was appointed UCSF associate dean for SFGH. He continued to function in
parallel as chief of Anesthesiology until the mid 1980s, when Cedric Bainton
succeeded him. Both ran an outstanding service and were well supported by
UCSF faculty and residents.
Ear, Nose, and Throat
Roger Crumley continued as chief of the ENT Service until 1979,
when he left to become head of the Department of ENT at UC Irvine. Thomas
Wild succeeded him.
Neurosurgery
Julian Hoff continued as chief of Neurosurgery until 1979, when he left
to become chair of Neurosurgery at the University of Michigan and a leader in
his specialty in the United States. He was succeeded by another excellent trauma
neurosurgeon, Lawrence Pitts, whose work in trauma set national standards in
his specialty.
Orthopedics
Ted Bovill remained chief of Orthopedics until his retirement in 1980.
He was succeeded by a controversial chief, Lorraine Day, who took issue with
many of the cooperative trauma practices of the Surgical Service. She was
hysterical on the issue of AIDS and refused to operate on patients who had
AIDS. She went on the national speaking circuit, emphasizing the AIDS risk to
surgical personnel. She espoused space suit protection for surgeons operating on
patients in a county hospital setting.
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Peter Trafton, a down-to-earth orthopedist, served as assistant chief of
orthopedics and continued the aggressive policy of early fixation of fractures.
Urology
Jack McAninch continued as the very
effective chief of Urology. He became recognized
as the number-one trauma urologist in the United
States, and he was elected to the Board of Regents
of the American College of Surgeons and the
American Board of Urology.
Plastic Surgery
In 1978, Luis Vasconez was appointed
chief of the Division of Plastic Surgery at UCSF.
Shortly thereafter, he recruited Robert Walton,
who had just completed his training at Yale, to be
full time head of plastic surgery at SFGH.
Bob Walton
Bob Walton proved to be an outstanding addition to the staff. He not only
covered plastic surgery but also took trauma call and became an intrinsic part of
the SFGH surgical family. He was well liked by the general surgery staff and
interrelated well with them. In 1979, he recruited Juris Bunkis as assistant chief
of plastic surgery and, during the three years Bunkis was at SFGH, he and
Walton were extremely productive. Walton's tenure lasted until the end of the
1980s.
CLINICAL PROGRAM
When Trunkey took over as chief of Surgery, it was clear that times
had changed. His management style was much looser than that of Blaisdell. The
staff were expected to assume more personal responsibility for making the
service run. This generated a warm and friendly environment in which staff
members were allowed to do their “own thing.” All they had to do was be
prepared to justify it. No doubt expectations were high, but Don Trunkey had
confidence in his faculty, and they in turn had the utmost confidence in him.
Initially, the service organization and call schedule continued pretty
much as it had under Trunkey’s predecessor. Gradually, as the service evolved,
modifications were necessary. The trauma faculty who did not live close by
were required to remain in-house when they were on call, as the new American
College of Surgeons (ACS) guidelines required that supervising faculty in
Trauma Centers must be immediately available.
Up until Proposition 13 resulted in major cutbacks in clinical programs,
SFGH had always been the major teaching hospital for UCSF’s students and
residents. Just over half of UCSF medical students and residents were assigned
to the hospital at any one time. All of the medical students were assigned to
SFGH for at least one rotation on Surgery during their junior year. Six faculty
members, with the help of volunteer clinicians from the community, did the
majority of the surgical teaching.
The number of elective cases declined on all SFGH services following
the restrictions on admissions generated by Proposition 13. Surgery was
particularly hard hit, and as a result the Extremity and Elective Services were
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combined in 1979-1980. This change was followed by a cutback in the number
of surgery residents assigned to SFGH.
This period also constituted the transitional phase from Blaisdell’s
philosophy that an exploratory laparotomy was a continuation of the physical
exam, to the modern notion that the use of emerging technology could improve
trauma evaluation. Under Trunkey’s leadership, CT scanning was established as
a valuable adjuvant to trauma assessment, permitting more effective screening
and the earlier discharge of patients.
In addition to trauma, there was an extraordinary number of cases of
gastrointestinal (GI) bleeding and pancreatitis on the Surgical Service due to the
large number of alcoholic patients treated at San Francisco General. Rich Crass
and Mike Federle were among the first to recognize the utility of the abdominal
CT scan in the evaluation and treatment of patients with severe pancreatitis.
Controversy regarding the management of GI bleeding led to a number of
randomized studies involving the Medical and Surgical Services.
OUTPATIENT DEPARTMENT
Initially, under Muriel Steele’s leadership, the clinic coverage
proceeded as before. Steele’s Colorectal Clinic was temporarily taken over by
Trunkey immediately following her death. Later it was incorporated into Rich
Crass’s GI Clinic.
Pictured from left to right are: unidentified lady, Don Trunkey, Mervyn Silverman, Director of
Public Health, To-Nao Wang, Surgical Resident, Sandy Libby, Head Clinic Nurse, Julius
Krevans, Dean and Chancellor of UCSF and Barrie Fairley, UCSF Associate Dean for
SFGH.
There was so much respect for Muriel Steele that a number of
significant dignitaries attended the dedication of the Surgical Clinic in her
honor. Bob Lim and Trunkey covered the Vascular Clinic and Art Thomas
covered the Thoracic Clinic. George Sheldon covered the Nutrition and Trauma
Clinics. Frank Lewis ran a Trauma and a General Surgery Clinic. Trunkey, and
later Tony Meyer, followed up burn patients. Bill Schecter and Bob Markison
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covered the Hand Clinic and extremity clinic in addition to Trauma and General
Surgery Clinics.
MISSION EMERGENCY HOSPITAL
The emergency room (ER)—Mission Emergency Hospital (MEH)—
was becoming an increasing challenge for the Surgical Service to manage. The
reason was that the ER was functioning more and more as a drop-in clinic.
Previously—before the introduction of Medicare and MediCal—a hard-nosed
attitude was taken toward patients presenting for emergency care. If the triage
nurse did not perceive that a true emergency existed, the patient was referred to
the clinics for care. As emergency rooms opened up in almost all of the hospitals
in the city, anyone who presented to these private ERs was examined and
treated, in order to justify staffing. The amount of money charged was of course
much higher than the charges for an equivalent emergency treated in a doctor’s
private office.
In order to compete and provide care equivalent to that in the
private sector, MEH accepted the task of treating everyone who presented. The
new ER had a “drop-in” area, which, as staffing became available, took
responsibility for the non-critical emergencies.
The basic character of the ER had changed, and the vast majority of
patients who presented for treatment required medical, not surgical, care. The
Medical Service was not willing or able to increase its staffing appropriately to
meet the needs of the ER. Blaisdell had hired an emergency physician, William
Teufel, hoping that he would start an emergency residency training program, but
Teufel wanted full administrative control of the ER before he initiated a training
program. This control was something the surgeons were not yet willing to give
up.
Bob Lim, who had headed MEH since 1968, became frustrated with the
difficulty staffing the ER, and Frank Lewis temporarily assumed charge in 19831984. Teufel, by that time, had gone ahead and initiated an emergency physician
training program. Lewis and Teufel came into conflict over administrative
responsibility for MEH and, as the result of the conflict, Teufel resigned. In
1985, Trunkey, frustrated by the staffing difficulties, reluctantly turned over
administrative control to Allan Gelb, an emergency physician. At the same time,
he insisted that Surgery remain in charge of all surgical and trauma triage and
treatment. Gelb proceeded to hire attending ER physicians to provide 24 hour
attending ER coverage.
In order to maintain the surgical presence in the ER, Trunkey hired
Mike Hickey, in 1985, to supervise the surgical residents and resolve the ER
surgical problems, The Surgical Service continued to rotate interns and junior
residents to the ER, but their responsibilities were now limited to surgical triage
and treatment. The Surgical Service remained in charge of all of the trauma that
presented, and worked cooperatively with the attending ER physicians.
THE INTENSIVE CARE UNIT
The director of the Intensive Care Unit (ICU) was Dick Schlobohm, a
tall, highly skilled Anesthesiologist from Iowa who was a commanding
presence. He administered the ICU and the Respiratory Care Service with
Prussian efficiency. Although all of the surgical ICU patients remained under
the control of the Surgical Service, a separate ICU Service rounded on the
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patients daily, managed the ventilators, and wrote the sedation orders. The ICU
resident staff was multidisciplinary. The residents covering the ICU rotated from
the Surgery, Medicine, and Anesthesiology Departments. There was also an ICU
fellow from a program run by the UCSF Department of Anesthesiology. Jim
Macho, in the middle of his residency, trained in this program in lieu of a
research year. The faculty were also multidisciplinary. Frank Lewis was the only
faculty member representing Surgery until Bill Schecter, and later Tony Meyer,
joined the group. At that point, Lewis, Schecter, and Meyer all became regular
members of the ICU faculty, in addition to their other duties on the Surgery
Service.
ICU beds were always at a premium and, on occasion, SFGH would
have to redirect trauma patients and critically ill patients to other hospitals due
to a lack of beds. This problem was an anathema to Trunkey, who urged his staff
to do everything possible to avoid diverting patients elsewhere. The diversion
could be disastrous for the hospital and the Trauma Program, for if trauma cases
could be diverted successfully to the private sector, then what was the
justification for the SFGH Trauma Program? The surgeons supervising the ICU
did their best to maintain the flow of patients by making rounds not only in the
Surgical ICU, but in the Medical ICU as well—keeping an eye out for empty
beds. This triage was initiated at all hours of the day and night, whenever the
hospital administrators threatened to divert patients to other hospitals. It was
usually possible to find a bed that the nursing supervisor had missed.
THE BURN UNIT
The Burn Unit was located in Ward 4J, across the corridor from Ward
4B, where most of the patients with soft-tissue infections were hospitalized.
Trunkey continued as director of the
Burn Unit until Tony Meyer joined
the faculty in 1982 and took over this
responsibility.
The head nurse in the Burn
Unit during this period was Mallory
Hondorp, an excellent nurse. Burn
care was evolving at that time.
Patients previously had been debrided
in a large tub of warm water under
inadequate sedation—a barbaric
practice. In 1980, this treatment was
abandoned in favor of excision of the
burn wound and immediate wound
Trunkey inspects burn patient
coverage in the operating room under anesthesia. Pigskin was used as a biologic
dressing for big burns. Burn wound sepsis remained a problem that was not
solved until the end of the 1980s, when immediate burn excision and coverage
with autograft or homograft skin was introduced.
The volume of burn cases began to decrease during the 1980s. In
addition to St. Francis Hospital, burn units were now developing at Alta Bates
Hospital in Berkeley, Oakland Children’s Hospital, UC Davis Hospital in
Sacramento, and the Valley Medical Center in Fresno. All competed for a
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number of patients that was decreasing, due in part to an excellent burnprevention program in Northern California.
When a nursing shortage developed in 1980, the Burn Unit was
temporarily closed and the excellent group of nurses dispersed. Burn care was
transferred to the ICU. When the Unit reopened a year later, it was with much
reduced resources. Henceforth, its orientation was primarily toward taking care
of burns on an outpatient basis.
Trunkey could rightfully claim some credit for the decreased number of
burn patients. In the 1970s, he joined forces with a political activist, Andrew
McGuire, and formed the Northern California Burn Council. This group was
active in promoting fire retardant children’s clothing, self-extinguishing
cigarettes, and burn-prevention education programs. When Trunkey became
chief of Surgery, the Burn Council was incorporated into the Trauma
Foundation, an advocacy group that helped pass the Motorcycle Helmet Law in
California.
Trunkey had a second agenda as well. He turned over responsibility for
Department Research Funds to the Foundation’s independent account, managed
by the Department’s administrative officer, Bob Steele. Steele promised to
handle them at much lower cost when they were free of the UCSF Dean’s
exorbitant tax. However, the extramural location of Department funds made it
easier for Steele to embezzle the money (see Finances).
THE AIDS EPIDEMIC
In the late 1970s, Muriel Steele began to see an increasing number of
gay patients in the Proctology Clinic who had a variety of complaints, including
anal warts, proctitis, diarrhea, anorectal ulcers, and the so-called “gay bowel
syndrome.” In 1979, gay patients with strange skin lesions began to present to
the ER and the clinics occasionally. The lesions proved to be a previously rare
disease, Kaposi’s sarcoma.
Bill Schecter was called to the Respiratory Medicine ICU on Ward 5R
in the spring of 1981. There, he saw a 33-year-old gay man dying of hypoxia
due to an unknown disease that was causing bilateral interstitial pulmonary
infiltrates. Schecter was unenthusiastic about an open lung biopsy because of
the high risk, but agreed to proceed. To everyone’s amazement, this young
man—despite the fact that he did not have lymphoma and had no history of
organ transplantation or immunosuppressive drugs—had Pneumocystis carinii
pneumonia. In the same year, outbreaks of Kaposi's sarcoma and Pneumocystis
carinii pneumonia also appeared in Los Angeles and New York. Trunkey
commented: “We didn’t know what the hell was going on. Nobody had a clue
that we were looking at an immune deficiency disease. Then it dawned on us, in
1981, that we were facing an entirely new disease that was devastating the gay
community—the Acquired Immune Deficiency Syndrome, AIDS.”
Initially, no one knew how this disease was transmitted—by aerosol,
the gastrointestinal tract, or by casual sexual contact. No one knew what the
incubation period of the disease was. In the early 1980s, before anyone knew
any better, many gay patients with generalized lymphadenopathy were
investigated by open lymph node biopsy. These procedures were frequently
bloody and large amounts of serous fluid would drain from the incisions.
Following the recognition of AIDS, surgeons would wrap themselves
in plastic garbage bags in a primitive attempt to decrease their risk exposure to
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blood and body fluids. As the death toll began to mount among these AIDS
patients, and as it became recognized that the incubation period was prolonged,
many of the staff in the hospital began to fear for their own lives. At the same
time, the affected patients suffered social ostracism. The gay community rallied
to the cause and established an incredible social service network to care for
affected patients. Political action groups formed who demanded more support
for research and improved treatment.
One of the UC surgical residents, Kay Riggs, came down with the
disease after having a blood transfusion. She died after a short, devastating
illness. The origin of the infection was not immediately determined, and this
added to the growing concern among all the doctors. At that time, blood
transfusion had still not been recognized as a cause of AIDS, and there was no
screening test for it.
Many nurses insisted on caring for the patients wearing a mask, gown,
and gloves. The hospital administration instituted a policy forbidding this
practice and subsequently fired three nurses who refused to comply, despite the
fact that there was no information on the effectiveness of this practice or lack
thereof. Trunkey responded to the concerns of the residents by telling them that,
if they didn’t want to operate on the patients, the attendings would do it. “You
don’t discriminate against AIDS patients! We were afraid, but we’re not going
to deny patients care because of it.” Bill Schecter provided an important
leadership role in setting up standards and safeguards for the emergency room
and the operating room for patients presumed to have AIDS. Human
Immunodeficiency Virus, HIV—the cause of AIDS—was discovered by Luc
Montaignier in 1983 and was confirmed by Robert Gallo in 1984.
Under the leadership of Paul Volberding in Medical Oncology, Donald
Abrams in Medical Oncology, Connie Wofsy in Infectious Disease, and Gayling Gee—an outstanding young nurse administrator—an outpatient clinic was
opened on Ward 86. In addition, a ward was devoted to the care of AIDS
patients—first Ward 5B, then Ward 5A.
The San Francisco General HIV program became a model for the rest
of the world. However, the surgical residents at the time nicknamed Ward 5A
“The Temple of Doom,” after a popular film of the era, because of the poor
prognosis for the AIDS patients. Treatment of HIV-infected patients was to
become a major focus of San Francisco General for the rest of the century.
THE RESIDENCY PROGRAM
All of the surgical housestaff were UCSF residents, rotating for periods
of one to two months. The resident staff were recruited from the best graduates
of the best medical schools in the country and were uniformly excellent. Most of
the graduates of the residency program went on to fellowship training or
academic jobs after completion of their training. In addition, there was usually a
resident from the California School of Podiatric Medicine assigned to the
Surgical Service.
There were now only two Surgical services, Trauma and ElectiveExtremity. All of the trauma and emergency surgery patients were hospitalized
on the Trauma Service, which was headed by a chief resident. The Elective
Service was run by a senior resident. In addition, if the chief resident did a
complex elective case, the patient was usually put on the Trauma Service so that
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the chief resident could more closely supervise the postoperative care. Burns
were also moved from the Extremity Service to the Trauma Service so that the
chief resident could control the care of the desperately ill patients.
The Elective-Extremity service covered non-emergency cases and softtissue infections. During this period, the shift to outpatient surgery for hernias,
breast surgery, and certain anorectal problems began. In parallel, the number of
soft-tissue infections due to drug and alcohol abuse increased. As a result, about
half of the hospitalized patients on the Elective-Extremity Service had softtissue infections.
Typically, a resident would spend one or two months on the Trauma
Service as an intern, another month as a junior resident, two months as a senior
resident, and one or two months as a chief resident. Interns and junior residents
would rotate for one- to two-month blocks on the Elective-Extremity Service.
UCSF surgical interns and residents also rotated through other SFGH Surgical
Services, such as Orthopedics, Neurosurgery, Urology, and Otolaryngology, as
well as the emergency room.
The residents all loved Don Trunkey because of his dynamic
personality. While he was chief, Don would make breakfast rounds with the
Trauma Team once a week. Trunkey would dissect an entire case with
incredible skill, making a lot of teaching points. When he was chief resident, Jim
Macho was present for the last Trunkey rounds. Jim catered breakfast and
presented Don with a “Certificate of Gratitude” for all of his teaching efforts.
MEDICAL STUDENTS
Shortly after Blaisdell left, the responsibility for the third-year medical
student clerkship shifted to Larry Way, chief of Surgery at the VA Hospital. As
a result of the decrease in elective cases at SFGH, the number of students
assigned to the Surgical Service was cut back, so all the students no longer had
rotations to SFGH for their required clerkship. However, thanks to Trunkey’s
dynamism and an excellent surgical staff, this service continued to be a popular
rotation for the students.
OPERATING ROOM & OPERATIVE CASES
The surgical suite consisted of eight operating rooms arranged in a
square around a central core containing supplies. Unfortunately, the main supply
area for the operating room (OR) was located in the basement. Although this
system was fashionable in the 1970s, when the hospital was designed, it was
inherently inefficient. It was fine for elective surgery, but created unavoidable
delays when unanticipated equipment or supplies were needed that were not
stored in the central core area. Room 1 was kept heated and constantly available
for major trauma cases. For practical purposes, only seven rooms—plus two
cystoscopy rooms—were available for elective and urgent cases.
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Barrie Fairley, a distinguished
anesthesiologist and pioneering intensivist,
directed the Department of Anesthesia. He
was a Canadian gentleman—a superb
clinician and an excellent clinical
physiologist.
He also served in the
important position as UCSF associate dean
for the SFGH campus during most of this
period.
Marge Matone was the Head
Nurse in the OR. She was energetic, highly
experienced, bright, and tough. She had
joined the OR staff right out of Nursing
School in 1954. She had a difficult,
stressful job, as the volume and complexity
of surgery was continually increasing and
Sheldon & Marge Mattone
resources were extremely limited. SFGH
lost an excellent nursing leader when she retired in 1988, after 25 years of OR
leadership—but she was a lot happier in her second career as a travel agent.
Clinical Cases: The incidence of trauma laparotomies dropped
progressively during this period as diagnostic screening became much more
sophisticated. Before the popularization of CT evaluation by Trunkey, peritoneal
lavage, an extremely sensitive means of assessment that could pick up small
quantities of blood, was in vogue. Moreover, Blaisdell had been aggressive in
his approach to trauma and had the philosophy that laparotomy was an extension
of the physical exam. “Patients don’t die from a negative laparotomy—they die
from missed abdominal injury.” This was given credence by Trunkey’s 1979
study with John West, and Bob Lim, published in the Archives of Surgery.
There had been a 30% negative laparotomy rate for stab wounds, but
with the introduction of CT evaluation, missed injuries became rare. In addition,
it was found that minor liver and splenic lacerations could be managed
conservatively if followed closely.
The introduction of H-2 blockers in the late 1970s resulted in a
dramatic reduction in the number of gastric operations for peptic ulcer disease in
the 1980s. The surgical staff flirted with the newly described highly selective
vagotomy in the late 1970s and early 1980s, but by 1986, most patients with GI
bleeding due to peptic ulcer were being managed medically. Simple plication
was used for most patients with perforated duodenal ulcers. The Medical
Service’s interest in endoscopic control of GI bleeding resulted in a conservative
approach regarding referral of these patients for operation.
GI bleeding due to variceal hemorrhage consumed extensive hospital
and ICU resources. Patients on the Medical Service could receive 20 or more
units of blood before they were referred to the Surgery Service. Two young
gastroenterologists, John Cello and Jim Grendel, working with Rich Crass and
Trunkey began to prospectively study the management of these difficult patients
(see Research Section). The recruitment of patients for randomized studies
meant that sometimes two or more ICU beds would be occupied by Child’s C
cirrhotic patients recuperating from portacaval shunts.
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End-to-side portacaval shunts were used initially, until Trunkey became
enamored with mesocaval shunts. Initially, he used a 30-mm Dacron graft,
which was “like suturing concrete (the graft) to tissue paper (the superior
mesenteric vein).” Later, he found that the harvested internal jugular vein was a
much better choice as the conduit. The Warren distal splenorenal shunt was
utilized for a brief period after it was described, but the improvements in
endoscopic sclerotherapy, and the subsequent development of esophageal
banding and the transjugular intrahepatic portacaval shunt (TIPS) procedure,
essentially ended operative portacaval shunting at SFGH.
Trunkey’s special interest in portal hypertension resulted in his belief
that the Leveen shunt and its modification, the Denver Shunt, should be used for
the management of intractable ascites. Many of the devices were placed in
alcoholic patients with end-stage liver disease and yielded mixed results. The
most devastating complication of this operation was disseminated intravascular
coagulation (DIC) resulting from the rapid infusion of ascitic fluid directly into
the circulation.
The large immigration from China and Southeast Asia in the 1970s and
1980s resulted in a steady increase in two diseases, Oriental cholangiohepatitis
and hepatoma. Cholangiohepatitis caused massive dilation of the extrahepatic
bile ducts that was associated with multiple intrahepatic duct strictures. The
ducts were filled with stones and sludge, which had the consistency of mud.
The etiology of this disease was unclear. Cholecystectomy and a wide side-toside choledochoduodenostomy proved to be the optimal operation for these
patients. The wide anastomosis allowed John Cello, a master endoscopist, to
enter the duct with a pediatric gastroscope and wash out soft stones in the event
of a recurrence.
Bob Lim was expert in the management of liver disease. He received
referrals for almost all of the patients with hepatoma as well as
cholangiohepatitis that occurred in the Chinese community. In addition, Lim did
most of the endocrine surgery as well—thyroidectomies, parathyroidectomies,
and adrenalectomies.
Lim provided vascular access for hemodialysis. Autologous
arteriovenous fistula shunts (when possible), bovine carotid artery grafts, and
later polytetrafluoroethylene (PTFE) grafts, were the types of access used.
Unfortunately, the late patency rates of the grafts were poor, which resulted in a
lot of suffering for the patients and a lot of time, energy, and frustration for Bob
and the residents, thrombectomizing or redoing occluded grafts and removing
infected ones.
Aside from the vascular access cases, the Vascular Service never
developed into a high-volume enterprise. About 60 to 80 major vascular cases
were done each year, including 10 to 12 carotid procedures.
Art Thomas covered the Thoracic practice, which included pulmonary
and esophageal malignancy cases, bleb resections, and pleurodesis for
spontaneous pneumothorax. Occasionally he treated a patient who had
pulmonary hemorrhage from tuberculosis, esophageal stricture due to lye
ingestion, or chronic pericardial effusion, usually due to uremia. Thomas was
also interested in gastroesophageal reflux, and he favored the Hill repair for
sliding hiatus hernia. The operations were challenging, and Art’s vast experience
and unique sense of humor added greatly to the residents’ enjoyment of the
cases.
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Hand surgery constituted a high-volume surgical activity. At that time,
all the injuries were treated immediately. The wounds were irrigated and closed
in the ER and the patients placed on the operating schedule. The low priority of
the cases, as compared with the gunshot wounds and stab wounds, meant that
the operations were often done in the middle of the night, placing a lot of stress
on the hand surgeons who were also taking regular trauma call. Bill Schecter
and Bob Markison did virtually all of the cases with the junior surgical residents.
Emergency room thoracotomy for resuscitation became a rite of
passage during this period, and residents were warmly congratulated after their
first experience. In 1979, Chip Baker—a resident who later became Trauma
director at the University of North Carolina, Chapel Hill, under George
Sheldon—reviewed the SFGH experience with 186 emergency thoracotomies
and reported an overall survival rate of 20%. The number of emergency
thoracotomies skyrocketed after that, exposing many residents and nurses to
blood in relatively uncontrolled situations—this at a time when the number of
HIV-infected patients was also rising dramatically. Bill Schecter arranged for
operating-room gowns and facemasks to be stocked in the ER. This process took
an incredible six months to work its way through the hospital bureaucracy.
RESEARCH
During Trunkey’s tenure, clinical research came to be emphasized,
rather than laboratory or bench research. Rich Crass developed a close working
relationship with two young gastroenterologists on the faculty—John Cello and
Jim Grendel. At this time, there were many alcoholics with portal hypertension;
patients with bleeding esophageal varices “were dying like flies.”
Sugiura of Japan had recently described an operation that involved
devascularization of the stomach and division of the esophagus. The esophagus
was then re-anastomosed, separating the azygous from the portal venous system
and thereby decompressing and controlling hemorrhage from the esophageal
varices. The end-to-end anastomosis (EEA) stapler had just been invented. Crass
came up with the idea of simplifying the surgical operation, using the EEA
stapler to simultaneously divide and staple the esophagus through a simple
gastrotomy. Unfortunately, the first 6 patients died of infected ascites, and the
study was abandoned.
Crass and Trunkey next collaborated with Cello and Grendel on a
randomized study comparing portacaval shunt surgery with sclerotherapy. The
mortality rate was 50% in both groups but the cost and length of hospitalization
was reduced in the sclerotherapy group in early follow-up. However, in longterm follow-up, there were more treatment failures in the sclerotherapy group
and the costs of surgery versus that for multiple hospital admissions for repeat
sclerotherapy equalized. This study resulted in two publications in the New
England Journal of Medicine. Nonetheless, endoscopic therapy basically
replaced the portacaval shunt as the primary treatment for bleeding esophageal
varices at San Francisco General.
Crass and Trunkey also collaborated with Mike Federle and Brooke
Jeffreys—two outstanding radiologists. They pioneered the use of the CT scan
as a “radiologic laparotomy,” paving the way for the revolutionary concept of
nonoperative treatment of selected injuries to the liver and spleen. Even within
the Surgery Department, CT remained controversial. Tony Meyer advised
nonoperative management of selected patients with CT evidence of liver injury
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at a teaching conference, and Lewis and Thomas vigorously attacked him.
Trunkey supported Meyer, and they subsequently published a series of
successful cases of nonoperative management. This concept became the
standard of care for specific types of liver injuries a decade later. Between 1965
and 1981, when DPL was used, it proved to be too sensitive, as 25% or more
laparotomies were “nontherapeutic.” The introduction of CT, as promoted
widely by Trunkey, changed this situation and constituted a major advancement
in trauma care.
In regard to bench research, George Sheldon succeeded Blaisdell as
chief of the Physiological Research Facility located on the third and fourth
floors of the Pathology Building, which contained wet labs and the animal
operating facility. Carol Miller, whose laboratory was actively involved in
studies of the immunology of trauma, was recruited to the University of
Massachusetts and left SFGH in 1979. Charles Graziano, her husband, who
worked in clotting research with Bob Lim, left with her. The laboratory was then
given to one of the Neurology faculty.
George Sheldon continued to lead the Program Project Grant in
Trauma. However, because of the loss of several critical investigators, the grant
was not renewed in 1981. Sheldon trained many research fellows, several of
whom have become distinguished professors in their own right. He had
organized the Nutritional Support Service and was actively involved in
developing this new field. He published papers on the nutritional and metabolic
needs of trauma patients. His research also involved blood and blood products,
and he was head of the Research Committee of Irwin Memorial Blood Bank.
Trunkey gave up his SFGH lab in order to develop a collaborative
arrangement with Ramachandran at UCSF, who was an adrenal specialist
studying secretion screening coupling.
Frank Lewis, whose interests were in Critical Care, was actively
involved in measuring lung water in critically ill trauma patients by using a
thermal dye technique that he had developed. His sheep experiments
demonstrated that sepsis resulted in diffuse lung permeability, and that
crystalloid resuscitation was more effective than colloid resuscitation.
NURSING
As a result of the hiring and wage freezes and staffing cutbacks that
followed the passage of Proposition 13, nursing staffing reached a critical point.
In 1979, the nurses went out on strike. This dispute was not resolved until
negotiations with the County Board of Supervisors resulted in an agreement to
ensure that patient–nurse ratios would not exceed eight to one. Admissions
would be stopped when the number of patients threatened to exceed this level.
The immediate result was to temporarily stop all elective admissions.
At one point, the emergency room was closed to all but cases of penetrating
trauma. The San Francisco Supervisors were forced to allow the hiring of more
nurses when eleven local hospitals refused to accept a medically indigent patient
with tearing chest pain due to a presumed aortic dissection.
Nonetheless, during this entire period, intermittent nursing shortages
continued to compromise patient care and stop the admission of elective cases,
which led to wild fluctuation in number of elective operations.
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FINANCES
Finances were a major problem for Trunkey and undoubtedly gave him
more headaches than any other aspect of the Department. At the time Blaisdell
left SFGH, the Surgical Department had four University FTEs and one City
salary—Muriel Steele’s for running the Outpatient Clinics. Blaisdell’s FTE
(salaried position) was lost with his departure, as was another when Sheldon left
in 1984. This meant that Surgery was thrown more and more on its own
resources, and the billing machinery had to become more efficient.
Art Thomas and Bob Markison convinced Trunkey to buy an expensive
computer system in order to facilitate billing and maximize income.
Unfortunately, this system proved to be a dud, and the Department ended up
paying for it for years. As the result, it constituted a drain on finances and
compromised rather than helped an increasing financial problem.
One partial solution was to utilize the Burn Foundation to handle
research grants and Department income. This resulted in a significant decrease
in the Medical School tax on grants and income. However, something was not
right. Despite an increasing clinical effort, income did not increase as it should
have. Larceny!
The UC-employed Department administrator, Bob Steele—who was
not related to Muriel Steele—was responsible. Bob was an affable, slightly
rotund man with a ready smile and expensive habits. He wore a Rolex watch,
drove a Porsche, and allegedly supported his lifestyle with a second job with
Amway. Bob was often the subject of faculty criticism at the weekly faculty
meetings—this activity seems to be a favorite faculty sport!—but otherwise he
seemed to be doing his work in a quiet way.
By 1985, it had become apparent that something was drastically wrong.
The University performed an audit, and Bob was arrested and later convicted of
embezzling what probably amounted to hundreds of thousands of dollars of
Department funds. The exact amount was never determined. This crime had a
major effect on UCSF financial policy, resulting in regular stringent oversight
and auditing of all departments.
NATIONAL TRAUMA DEVELOPMENT
It was during this period that Donald Trunkey’s activities became
international in scope. He, more than any other person, was responsible for the
development of Trauma Programs throughout the United States. His review
comparing two counties, San Francisco and Orange County—the former with a
well-organized trauma system, the latter with none—received national attention.
A review and re-review by outside experts showed that at least 25% of the
trauma deaths in Orange County, as opposed to a mere 1% in San Francisco,
were preventable. When reviews were carried out in any area without organized
trauma care, similar statistics prevailed.
A County survey followed, which showed that, in the nine counties
surrounding San Francisco, each year there were 7 to 10 patients dying of simple
injuries that went unrecognized or were treated too late. A news reporter asked
why Marin County, which was the worst, had no trauma centers. Trunkey’s
much quoted response was, “That was their attempt at population control.”
During the period 1982-1986, Trunkey was chair of the American
College of Surgeons Committee on Trauma (COT). Under his leadership, the
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Committee promoted Advanced Trauma Life Support (ATLS) for all physicians
involved in trauma and emergency work. This trauma resuscitation program had
been developed in Nebraska under the leadership of Skip Collicott. ATLS was
adopted as a requirement for physicians by the military and by nearly all of the
major emergency rooms in the Country, thanks to COT’s promotion effort.
As was often the case in his career, Trunkey pushed some things that he
believed in further than the political process would accept. In September 1983,
he had a brief meeting with Rollo Hanlon, director of the American College of
Surgeons (ACS), in which he espoused the importance of developing criteria for
and then certifying the trauma programs that were developing in hospitals
throughout the United States. Assuming that agreement had been reached, his
committee started certifying trauma programs. The requirements were such that
few programs passed and a political outcry went up. Hanlon expressed outrage
that the ACS Board of Regents had been bypassed. Trunkey was asked to appear
before the Executive Committee of the Board, accept a tongue-lashing, and
discontinue his certification program. The certification process was turned over
to the individual states and later the COT was allowed to verify that the state
approved programs were following the accepted ACS guidelines. As a result of
Trunkey’s ministrations, some 1,100 trauma centers were certified in the United
States.
At the same September meeting, Trunkey attempted to get the Regents
to assume responsibility for a National Trauma Registry. Hanlon turned this
proposal down, and it was only in 1999 that this became a reality.
Trunkey also became an advocate of disaster planning, and he proposed
that SFGH assume the role of a regional resource. His initial effort was not
received favorably. The effort involved a major bus accident in Martinez,
California in 1976, in which 29 of 51 children were killed and 22 were injured,
many trapped in the overturned vehicle. Trunkey sent a team to the accident site
and Frank Lewis carried out triage. Bill Schecter, a resident at the time, hand
ventilated a critically injured girl during the ambulance transfer to SFGH.
Trunkey was called to a hearing before the San Francisco Board of Supervisors,
who objected to using SFGH resources for an accident in another county. The
head of San Francisco’s Emergency Care Committee, Marguerite Warren, an
imposing woman with great political power, defended Trunkey, and the Board
sheepishly agreed with his action.
The Trauma Foundation was a major force in trauma prevention. As
noted in the previous chapter, it was Trunkey who offered Andrew and Kay
McGuire space in Blaisdell’s old laboratory on the third floor above the old
Mission Emergency to house their Foundation. Shortly thereafter, Andy was
appointed a MacArthur Fellow—a prestigious scholarship that provided support
for his salary and for his activities in burn prevention. It provided tax-free
funding for a full five years.
POLITICAL RELATIONSHIPS
This was an extremely turbulent and unstable period for SFGH. Charles
Windsor, the first well-qualified administrator since the institution of Medicare,
resigned in 1979, when the City’s chief administrative officer (CAO), Roger
Boas, interfered with his internal decisions regarding how to manage the
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cutbacks necessitated by Proposition 13. Walter
Coulson’s resignation as medical director and
associate dean immediately followed, when Boas
tried to put a restriction on blood utilization and
the purchase of xray film.
Boas was a prominent former auto
dealer in San Francisco with no prior medical or
administrative experience. He was a callous,
ruthless individual who rode roughshod over all
the City-County agencies under his control—and
they included the Department of Public Health
and the County Hospital. He took office in 1977
with a plan to close down the County Hospital,
or at least distribute all its paying patients to the private sector. It was during this
period that he advocated that the ambulances take all paying trauma patients to a
private hospital. At a public meeting, Trunkey asked, “What are we supposed to
do, carry out financial triage in the ambulance?”
The attempt to redistribute trauma care immediately broke down.
Following admission of trauma cases to private hospitals, the staff proved
disinterested in or incapable of handling them. As the result of several wellpublicized catastrophes, the attempt was quickly aborted. Fortunately for
everyone, Boas was caught in a scandal involving teenage prostitutes and he was
forced out of office. Responsibility for the hospital was transferred to the Mayor,
as it was felt that—because he was an elected official—he would be more
responsive to the needs of the patients.
During Trunkey’s eight-year tenure, he had to deal with two directors
of Public Health, six hospital directors, and two Nursing directors. This turnover
obviously resulted in an unstable administrative environment. During this
period, Trunkey was called on frequently to defend the hospital’s budget before
the Board of Supervisors and to mount a constant lobbying effort to avoid
financial cutbacks in the hospital budget.
Relations with UCSF were mixed. The chair of Surgery, Paul Ebert,
left SFGH alone. He did not interfere, nor did he supply any resources.
The Dean, during much of this period, was Rudy Schmidt. His
relationship with Trunkey was hostile, to say the least. Trunkey’s forthright
manner deeply offended him and, when Ebert retired, Schmidt informed the
Search Committee for the new UCSF chair of Surgery that Trunkey was not to
be considered under any circumstances.
ANECDOTES
Office Accoutrements
The first thing visible on entering Don Trunkey’s office were two xrays
illuminated by the xray view box. The first was a KUB demonstrating a huge
dildo in the left colon, extending all the way up to the splenic flexure. The
second was a skull film xray depicting a large knife within the cranial vault. On
the wall was a plaque prominently displaying every known type of bullet. A
large spray can sat on his desk facing his visitors, emblazoned with the words
“Bullshit Repellent.” Faculty meetings were held in Don’s office with chairs
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positioned in a semi-circle, facing his desk. On the wall behind Don, in full view
of the faculty, was a picture of a goofy-looking bird with the accompanying
phrase: “It’s hard to soar like an eagle when you’re surrounded by Turkeys!”
(…as told by James Macho and Arthur Thomas)
ET Call Home
At about this time, there was a popular movie entitled “ET” that was
about an extraterrestrial being who arrives on earth, befriends a little boy and his
family, and desperately tries to make contact with his home planet. Tony
Meyer—ever the practical joker—obtained two ET posters with the slogan, “ET
Phone Home,” which were used to market the film. He pasted a picture of Don
Trunkey’s head over the head of ET and changed the lettering to read “DT
Phone Home!” He placed one full-size poster in Don’s office and gave the
second one to Jane Trunkey. Don rolled in one afternoon from the airport and
opened the door of his office, only to be faced with a full-length poster reading
“DT Phone Home!” He was not amused. Shortly thereafter, the poster
disappeared. However, when he returned home that evening, he found an
identical poster hanging in his home! He did not have as much success in
disposing of the second poster. (…as told by Tony Meyer)
World Traveler
As in all families, the foibles of the “pater familias” are the subject of
great jest and ridicule. Don’s extensive travel schedule was the target in his case.
He maintained both “his personal and the departmental mystique” through his
innumerable national and international speaking engagements. This frequency of
travel became the source of much discussion and mirth among the faculty, much
to Don’s annoyance. He always took his share of trauma call, but he was
usually away if he wasn’t on call. Don would frequently hold staff meetings
with a suitcase next to his desk. When he was chief of Surgery, many of the
staff had the feeling that everyone else in the world saw more of him than they
did. The chief residents had a map of the United States posted in their call room
and would place a push pin in each city that Trunkey visited. The map was
covered with pins. …as told by James Macho)
An Affluent Office
When Robert Walton arrived as SFGH chief of Plastic Surgery, Don
Trunkey showed him around and then took him to his “temporary office,” which
was a janitor's closet on the third floor. “Don promised me a larger office 'soon.'
I remained in my 6 x 8-foot cell for the next four years. I was actually offered a
larger office in the third year, but I gave it to Juris Bunkis as part of his
recruitment offer. It is difficult to recruit to a janitor's closet.”
Hot Times
Initially, Don Trunkey and George Sheldon lived across the street from
one another in Hillsborough. Don and Jane had rented a home that had been the
former Finland Consulate—it had a sauna in the back yard. George and Ruth
enjoyed using the sauna, but created a local scandal when the neighbors noted
them crossing the street in their bathrobes in the evening. (…as told by Arthur
Thomas)
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Party Time
When the Surgery Department was solvent, black tie dinners were held
at Trader Vic’s in San Francisco on the occasion of the graduation of chief
residents or the departure of
faculty members for new jobs.
Art Thomas, who was in charge
of these events, would organize
the rotation of tables at each
course so that the maximum
amount of social interaction
occurred.
This rotation was
logistically difficult, as the
guests would be drinking Trader
Vic’s potent Stinger and Mai Tai
from group punch bowels, so
they would have no way of
measuring the quantity of
alcohol consumed until the
clinical
signs
of
alcohol
intoxication became manifest. At
each rotation, the guests would Don and Jane Trunkey Enjoy
have to take their own straws for insertion into the next punch bowl. By the
third course, navigation between the tables became somewhat of a challenge.
(…as told by Bill Schecter)
“Uncle Art”
Art Thomas developed a close personal relationship with many
residents. He loved to sit in his office with the senior residents, sometimes for
hours, discussing cases and drinking warm Diet Coke. He kept a case of Diet
Coke in the office so he was always well supplied. Football was a quasireligious experience for Art, and he worshipped at Candlestick Park where he
maintained season tickets. Many of the residents joined him for a weekend
brunch at his lovely home in Hillsborough, following which they would all
repair to Candlestick Park to watch Joe Montana and the 49ers continue their
march to another Super Bowl appearance.
(…as told by James Macho)
A Magnet for Nurses
Frank Lewis was an absolute magnet
for nurses. He attracted the attention and
affection of many of the most beautiful and
intelligent nurses in
the hospital.
All of his old girlfriends
remained remarkably devoted to him
throughout the years.
(…as told by Bill
Blaisdell).
Janet Christensen, Frank Lewis,
Donna D’Acuti, Phyllis Harding (top)
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Married To a Wonderful Guy
Shortly after George Sheldon and Tony Meyer moved to the University
of North Carolina (UNC) at Chapel Hill in 1984, Don Trunkey was at a national
meeting and met a UNC burn nurse who worked with Tony. Don casually asked
if she had met Tony’s wife. “Why, no,” she replied. “You should,” said
Trunkey, “he’s a wonderful guy.” This information, though false, would have
hardly raised an eyebrow in San Francisco, but was scandalous news in North
Carolina. When the nurse returned home, she mentioned that she had met
Trunkey. “All right,” said Tony, “what did he say about me?” It took 20
minutes to pry the story out of her; they had a good laugh when Tony explained
Don’s sense of humor. (…as told by Tony Meyer)
Revenge Is Mine
Two years later, Tony got his revenge when Don moved to become
chair at the University of Oregon. Tony sent him an anonymous one-year’s gift
subscription to The Advocate, a national journal for gay men and lesbians, and
addressed it to Trunkey at the Department of Surgery, University of Oregon
Health Sciences Center. Shortly after passing through the mailroom and the
hands of several secretaries, the whole hospital knew of the subscription!
Television Star
At the time, there was a television show called Lifeline that filmed
various prominent doctors performing acts of “daring-do” and featured one
doctor each week. Surgeons were usually the featured subjects, and inevitably
Trunkey was the hero of one of the shows. Unfortunately, work in the OR was
uncharacteristically slow during the several days that the camera team spent
following him around. They showed a segment of Trunkey treating a fracture
and another of him participating in resuscitation in the burn unit, chewing out a
clinically immature resident. One particularly memorable segment was a fullface closeup of Trunkey leaning over an ICU patient speaking words of
encouragement, explaining to the patient that he was going to evaluate his
breathing and that he would remove his endotracheal tube. This segment
enraged some anesthesiology-ICU doctors because Trunkey never personally
evaluated the airway and never personally removed a patient’s endotracheal
tube. (…as told by Arthur Thomas)
Survival of the Fittest
Don Trunkey is a guy who, if you threw 100 people overboard, he
would be the first to rise to the surface. (…as told by Art Thomas)
Early Bird
Walking to work every day from my home on Potrero Hill, I would see
Don’s Mazda sports car parked in the Trauma Attending emergency parking
spot opposite the entrance to the emergency room. The license plate read
“Trauma 1.” (…as told by Bill Schecter)
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A Nobel Hit
In 1982, Joe Murray—Nobel Laureate, organ transplant pioneer, and
Harvard Medical School professor of Surgery—was visiting professor in Plastic
Surgery at UCSF. I was pleased to bring him to SFGH in my sparkling new
Volvo for a tour and rounds with the residents. We drove into the parking lot
and pulled up alongside Don Trunkey's car. Joe flung his door open, whacking
the side of Don's car and putting a visible dent in the side of my new car's door.
He bent down, did a once over, closed the door and walked away. I was
horrified! Not only had he put an obviously visible dent on the side of Don's car
with my car's paint inscription, but he had permanently marred my NEW car.
Murray never mentioned the incident. I bit my tongue, swallowed my pride and
accepted Joe Murray's baptism of my new car. Don Trunkey never noticed and I
never told him. I was very fortunate because Don came to work in the dark and
went home in the dark (…as told by Robert Walton)
CASES
Mellow Yellow
In the spring of 1979, after several days of feeling weak and tired,
Trunkey turned yellow, and hepatitis was diagnosed. He was still taking call that
night when Schecter, then chief resident, notified him that he was taking an
elderly man with a leaking abdominal aortic aneurysm to the operating room.
Trunkey dutifully appeared and the operation went well. Immediately following
the case, Don took an extended vacation to Washington to recover from the
disease. This was an example of Don Trunkey's unsurpassed commitment to his
patients, placing their interests above his own. (…as told by Bill Schecter)
A Breathtaking Experience
A 19-year-old woman was struck by a car and admitted to the
emergency room, stable but with opacification of the right hemithorax. The
residents initiated positive-pressure breathing treatment, which resulted in a
continuous major air leak and the need for endotracheal intubation.
Bronchoscopy in the operating room disclosed a right main stem bronchus
transection. Schecter, uncomfortable with the problem, called Trunkey, who
came in and provided support while Schecter and his chief resident repaired the
injury. It was an example of how Trunkey provided support and guidance so that
his junior faculty and residents could develop their clinical skills. The young
woman did well and went on to employment as a flight attendant. (…as told by
Bill Schecter)
Lifeline Come Back
Lifeline was a television series in which the camera followed a specific
surgeon’s activities. They did an episode on Paul Ebert and neurosurgeon
Charles Wilson, and Don Trunkey’s installment was the third. A young
prostitute, who had been shot multiple times by her pimp, was admitted to
Mission Emergency in profound shock, resuscitated and taken immediately to
surgery. There was a gunshot wound of her neck and another to her abdomen.
Don controlled the bleeding in the abdomen; and the liver, pancreatic, and bowel
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injuries were treated successfully. The bullet to the neck had produced
quadriplegia from a C-2 spinal cord injury. She was kept alive in the ICU for
several days, but there was no spontaneous respiration, so the endotracheal tube
was removed and she was allowed to die. This was too much for Lifeline, and
they came back for an alternative case. This time, Trunkey reduced a dislocated
thumb for a six-year-old child in the ER and operated on a popliteal artery
injury—“much better cases.”
Following the death of the quadriplegic patient, the family, who had not
shown up while she was alive, instituted a lawsuit for $100 million! The suit
was later dropped, as it was decided that the family had no case. The patient's
injury was irrevocably lethal.
ACD Arrest
A six-year-old child was struck by a car and admitted to the trauma
resuscitation room. The patient was stable and the nurse left the resuscitation
bay, leaving the child with an intern who was rotating from another residency
program for trauma training. When the child’s intravenous solution ran out, the
intern grabbed another bag off the shelf and hung it in the place of the empty
bag. It was ACD (anticoagulant-citrate-dextrose) solution and, after the child
had received 50 ml, he developed cardiac arrest. Trunkey and the chief resident,
Rich Carmona, immediately did a left thoracotomy and resuscitated the child.
He required heroic measures in the ICU, but eventually recovered. The family
was told the reason for the arrest and they instituted a lawsuit against the faculty,
alleging brain damage from faulty treatment. The suit was dropped when the
University lawyers found out that the child had been documented as mentally
impaired before his injury.
A Chilling Experience
Bill Schecter typically would start off every work day with a swim in
San Francisco Bay at Aquatic Park. One day in late December, when his alarm
went off at 4:45 AM, he stuck his head out of the covers and realized that it was
absolutely freezing out. He shut off the alarm and went back to bed. When he
arrived at work at 7:15 AM, he was shocked, on making rounds in Mission
Emergency, to see one of his friends brought in profoundly hypoxic after
suffering a near-drowning event due to hypothermia. Vascular access and
endotracheal intubation were accomplished, but with great difficulty because the
very fit and strong swimmer was desperately struggling due to hypoxia.
Fortunately, after 36 hours of mechanical
ventilation, pulmonary function improved and
the patient survived.
Seeing Stars
One of the most dramatic and
newsworthy cases was the case of Janet
Gaynor and Mary Martin—two elderly movie
stars who were injured when their taxi was hit
by a drunken driver in downtown San
Francisco in 1982. Both were severely injured
and had multiple fractures. Gaynor was in
shock at the time of admission. Frank Lewis
Mary Martin with her savior
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supervised the resuscitation and treatment. Mary Martin left the hospital within
the week, but Gaynor remained in the ICU and in critical condition for many
weeks. She was finally discharged, but she died six months later as an aftermath
of her injuries.
Mary Martin, in gratitude to the hospital staff, put on a benefit program
for the Trauma Program in the new San Francisco Opera House. She reproduced
her flying wire act from Peter Pan and obtained the participation of many
Hollywood celebrities for the event. Don Trunkey was featured in several of the
short plays and had the distinction of being propositioned by one of the
celebrities participating in the show.
Catastrophe at City Hall
The phone in Mission Emergency rang off the hook immediately after
the shooting of San Francisco Mayor George Moscone and Supervisor Harvey
Milk by ex-Supervisor Dan White in November 1978. The ER immediately
paged Trunkey, who was holding Vascular Clinic at Laguna Honda Hospital.
Trunkey drove at breakneck speed back to Mission Emergency to discover that
both had been declared dead at the scene. White had shot both of them in the
chest and then in the head.
A Problem Patient
When Bill Schecter was a senior resident, he was admitted to the SFGH
emergency room at 5 AM with right upper-quadrant pain, fever, and
leukocytosis. After innumerable tests were done, including a lumbar puncture,
John Mills, chief of Infectious Disease, made a working diagnosis of brucellosis.
Schecter was sent home on hospital day number four. He remained ill and
returned to the hospital 48 hours later with boring back pain, informing Trunkey
that he needed “to be treated with sixty cents worth of surgical steel.” After
removal of a necrotic, perforated, retrocecal appendix and subsequent drainage
of a subfascial wound infection, he made a complete recovery.
However, in future years, whenever a resident presenting a
complication was criticized for not getting an attending involved in the care of
the patient sooner, Schecter would chime in, “But, I had an attending taking care
of me and look what happened.” This remark of course would elicit laughter
from all assembled who knew the story. Don Trunkey would turn pink, smile
sheepishly, shake his head and say, “Schecter, you’re like an albatross around
my neck.” (…as told by Bill Schecter)
ICU Crisis
One night, after Bill Schecter had gotten up at 1 AM to find a bed for a
patient, he received another call at 3 AM to tell him that the last ICU bed had
been given away. The nursing supervisor asked if she should go “on divert”.
As Trunkey had instructed his faculty “never to go on divert,” Schecter told the
nursing supervisor that he would come in personally to nurse the next patient, if
necessary. An hour later, the nursing supervisor called him on his pledge, as
another patient had been admitted to the ICU. Schecter drove into the hospital to
find an unfortunate young man with a massively distended abdomen due to
malignant ascites from metastatic rhabdomyosarcoma. The patient had arrested
on the Medical Service and had just been resuscitated. When asked why this
poor patient had been resuscitated, the young medical intern looked up and, with
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a straight face, informed Schecter that there was a 2% chance of survival with
chemotherapy.
Schecter replied, “Yes, Doctor.” He changed into a scrub suit and
nursed the patient until a medical “grown up” arrived in the morning and
withdrew support. However, the nurses were offended that Schecter had had the
audacity to think that he could competently nurse an ICU patient. They “let it
all hang out” in a sensitivity training session. (…as told by Bill Schecter)
Dos Equis
Bill Hoffman, then a fellow in Plastic Surgery, called Schecter about a
young man, the son of a minister, who had amputated his own hand. There was
an XX tattooed on the hand—the sign of the Devil. Schecter was not
enthusiastic about replanting the hand because of his previous experience with a
psychiatric patient who would not cooperate with rehabilitation. However, at the
urging of his parents, Schecter and Hoffman replanted the hand. The procedure
was successful. For years afterward, Schecter received a handwritten Easter
card, written with the replanted hand. The lesson he learned from this patient
was, “The initial prognosis for either life or function may be incorrect. Every
person deserves a chance.” (… as told by Bill Schecter)
Cowboy Don
When Schecter was a young attending, he consulted on a medical
patient who had what appeared to be a septic abdomen. The medical resident
and intern were hell-bent on doing a diagnostic paracentesis. Schecter had
already concluded that the patient needed an exploratory laparotomy and felt
that needle aspiration might unnecessarily injure the bowel. Just at that moment,
Don Trunkey, not aware of the decision, cruised by the ICU, saw the patient
and—without asking anyone—immediately stuck a needle into the patient's
abdomen and announced that the patient needed surgery. The enraged medical
housestaff complained to Schecter, who broke out laughing and told them, “Don
still thinks he's on television.”
A Necessary Conversion to Christianity
A young Gypsy boy sustained a severe head injury in an auto accident,
and the whole Gypsy clan descended on the hospital. Several nights later,
Schecter received a desperation phone call from his chief resident. A hundred
Gypsies had him backed against a wall, threatening him with bodily harm if the
patient succumbed to his injury. Schecter went to the hospital—but, at that time,
he knew little of the Gypsy culture. In searching for a way to describe the boy's
dire situation, he explained that the boy was being held in the hands of Jesus and
that Jesus would decide whether or not to take the boy to his breast or return him
to the world. To Schecter's amazement, 100 Gypsies in unison raised their hands
to the ceiling and shouted, “Jesus, Jesus, he's the man.” All tension immediately
lifted, and the meeting broke up. The next day Carol Fink, a psychiatric nurse,
met with two leaders of the Gypsy clan. The two gentlemen, who were referred
to as Gypsy Kings, observed that Schecter seemed to be a very religious
Christian. Carol, who knew that Schecter was Jewish, smiled and asked why
they said that. They immediately replied, “Every time we see him, he always
talks about Jesus.”
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A Jolting Experience
There were always characters who appeared in the emergency room,
hoping to be admitted for either feigned or psychosomatic illnesses. One
“frequent flyer” was an African American man named Moses, who worked the
system for all it was worth. He not only used SFGH, but also the VA and Mount
Zion Hospitals as well. Although he manipulated the system, all the nurses and
surgical residents viewed him with affection and tolerance. The City ambulance
drivers were on to Moses as well. One day, after failing to convince the City
paramedics to transport him to SFGH for imagined complaints, Moses faked a
cardiac event. For some reason, a private ambulance crew who did not know
him was called. When they saw him in an apparent collapse on the street, they
immediately applied a defibrillator, which actually did induce cardiac arrest. He
was transported to the hospital, but unfortunately did not survive. Moses had
finally outsmarted himself.
TRUNKEY’S DEPARTURE
In 1984, George Sheldon and Tony Meyer left to go to the University
of North Carolina. Shortly thereafter, the UCSF Department of Surgery
underwent a major change. Paul Ebert, the chair at UCSF, announced that he
was stepping down to assume the position of director of the American College
of Surgeons. Don Trunkey had hoped to compete for the chair of Surgery at
UCSF. However, the new Dean, Rudi Schmidt, informed the Search Committee
that under no circumstances would Trunkey be selected for this position. Don
decided it was time to leave. After looking at chair positions in San Diego,
Colorado, and Kentucky, Don accepted the chair at the University of Oregon in
1986, taking Rich Crass with him.
Don’s departure was a major event. A full-page spread appeared in the
San Francisco Chronicle describing his career. The Department organized a
good-bye party at Trader Vic’s and presented Don with an antique clock worth
$4,000. Bill and Gisela Schecter threw a barbecue in honor of Don and Jane at
their house in Half Moon Bay with 120 people in attendance. Don’s
innumerable friends organized a “roast” for him at Bimbo’s, a famous nightclub
on Columbus Street that was attended by a huge crowd of people who loved and
admired him.
STAFF MEMBERS’ MEMORIES OF THE TRUNKEY YEARS
Robert Markison recalls…
“There was no SFGH way or Trunkey way.” When Trunkey took over,
it was clear that times had changed. “The vertical military pyramid of
responsibility was adapted to become a shared responsibility. Don Trunkey
understands ‘ensemble’ better than most surgeons ever could. We had the belief
that we had ‘taken on the mantle of Guardian of the City’, and that we all shared
a deeper social contract and bond. We had entered a dramatic realm beyond the
average elective surgical practice. When Don became chief in 1978, he did not
‘take out the blame book’. It was very much ‘forgive and remember’. Don, as a
boss, was very much hands off. You could do your own thing as long as you
could justify it. The social atmosphere in the Department under Don was warm
and relaxed. Despite his big name and reputation, Don was not egotistical,
which was both disarming and inspiring.”
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Richard Crass recalls…
Trunkey recruited people who were excellent all-around surgeons. He
did not go after specialty surgeons, as he felt that the nature of the practice at
SFGH was such that you had to be prepared for anything that came in. The
atmosphere in the Department was very upbeat. For the young faculty recruits,
the job at SFGH was a “dream come true”.
Arthur Thomas recalls…
At a meeting of the American
Association for the Surgery of Trauma,
Don Trunkey showed up for a total of
four hours to discuss one paper. For the
remaining days of the meeting, many of
the other discussants quoted Trunkey, as
if to bask in the reflected glory of his
name, despite the fact that he wasn’t
there.
He, in effect, dominated the
meeting in absentia.
Don was clearly destined for
further leadership positions. He was
extremely agile with impromptu speeches.
At one dinner for Examiners from the
American Board of Surgery, hosted by the
Department of Surgery, he publicly
introduced, in a most amusing and
personal manner, without notes, each of
the approximately 50 seated guests.
Father Trunkey
Anthony Meyer recalls…
The County hospital and the people who work there are truly unique. I
know of no place that melded people together or developed such an esprit de
corps. You could always count on people there not only to do their share, but
more than their share. This was the hardest thing about leaving the County and
taking the job in North Carolina.
Robert Walton recalls…
Don Trunkey was a great chief. He was a benevolent leader who had a
great sense of organization. He inspired all of us. Don encouraged me to pursue
the microsurgery initiative at SFGH, and under his guidance and support, we
began performing free tissue transfers routinely. Our biggest problem with Don
was his incessant traveling.
Bill Blaisdell recalls…
Don Trunkey is larger than life, and one runs out of adjectives
describing him. When put before an audience, he is like the greatest actor—he
dominates any scene. He is quick on the quip, usually in a humorous vein. On
the numerous occasions that we have appeared together, many observers have
182
drawn the conclusion that he trained me, rather than vice versa. I would like to
credit that to my youthful appearance, but I am told that is not so!
In many respects, I feel like his “Daddy.” During his junior years, he
reminded me of my teenage boys—always in trouble, but at the same time
winning the big game and making me extremely proud and enabling me to bask
in his glory.
Had he embarked on a political career—which he actually considered
on a number of occasions—he might have reached the highest office in the land.
He certainly would have made one of the greatest evangelists this country has
ever seen, were he to have pursued that route. Actually, in many respects, he
did, as he was and is the “St. Paul of Trauma,” spreading the trauma gospel
throughout the world. No one brought the message of the importance of
organized trauma programs in saving lives so magnificently. It is probable that
he, with his evangelism, has saved more lives than has any other current
physician in the United States. Before he so forcibly spoke up, the average
preventable death rate from injury in the United States was 25% or more—but
when a community organized a trauma program, deaths fell to negligible levels.
No recitation of Don’s accomplishments would be complete without
acknowledging his wife, Jane Henry Trunkey. She has been a martyr to the
cause, giving Don the freedom to pursue his mission, for he is always on the
road. Very few marriages would have stayed intact under Don’s commitment to
work and travel. Perhaps this is possible because a little of Trunkey goes a long
way!
Bill Schecter recalls…
Don Trunkey's tenure as chief of Surgery at SFGH was marked by
great personal success and advancement. During this period, he served as chair
of the Committee on Trauma of the ACS and introduced the Advanced Trauma
Life Support (ATLS) and the Level I Trauma Center certification program. His
promotion of trauma care worldwide has saved countless lives.
He ran his Department like a family and provided friendship and
support for both his faculty and his residents. Each fall, Don would host a beach
party at his house in Montara for the incoming interns and residents—a
wonderful social event. My family particularly enjoyed barbecues on the beach
with Don and Jane.
He was an absolutely superb and committed teacher. He exhibited
affection and concern for his patients, their families, and the nursing staff, as
well as for the faculty and residents. Don is clearly unsurpassed as a leader.
When he is around, he makes things happen. Were he to command men in war,
he would be out front leading the charge and, provided that he survived, he
would win the glorious battle. His infectious enthusiasm knows no bounds.
When his way is blocked by a mountain of obstacles, he can stimulate his staff
to help clear the way by convincing them that a pile of gold must lie beneath!
I owe Don a tremendous personal debt. His friendship, support, and
trust permitted me to return to SFGH from a three-year sojourn overseas, and
enabled me to pursue a career in academic surgery.
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CHIEF RESIDENTS — THE TRUNKEY YEARS
1978-1979
Clark Boren (Buz)
Richard Crass (Rich)
Richard Margules (Rich)
Constantine Mavroudis (Gus)
James Raffa (Jim)
William Schecter (Bill)
1982-1983
Robin Bernhoft
Ning Chang
Steve Granelli
William Hoffman (Bill)
Jeannie Thomas
Robert Tranbaugh (Bob)
1979-1980
Armando Giuliano
Kenneth McIntyre (Ken)
Gregory Misbach (Greg)
Neil Rudo
John Van Speybrock
James Harwood
1983-1984
Verna Gibbs
David Knighton
Donald Nakayama (Don)
Stefanie Jeffrey
Carlos Weber
Michael Wood (Mike)
1980-1981
Bruce Allen
Charles Baker (Chip)
Lawrence Colen (Larry)
Robert Markison (Bob)
Scott Replogle
Edward Yee (Ed)
1984-1985
Richard Carmona (Rich)
John Donohue
Robert Mackersie (Bob)
Scott Merrick
Louis Messina (Lou)
Kay Briggs
1981-1982
Milton Brinton
Anthony Meyer (Tony)
Jeffrey Symmonds (Jeff)
Edward Verrier (Ed)
To-Nao Wang
Wendel Wenneker
1985-1986
Frederick Bongard (Fred)
James Economou (Jim)
Phillip Glick (Phil)
Frank Hanley
Craig Kent
James Macho (Jim)
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RESEARCH FELLOWS
1978-1979 Susan Briggs (Miller).
Shock research with Trunkey (MGH)
Professor of Surgery MGH
1978-1979 Steven Hill (UCSF)
Worked with Frank Lewis
Went into private practice
1979-1981 Robert Tranbaugh (UCSF)
Worked with Frank Lewis
Awards: National Residents Research Award
ACS Committee on Trauma award, 1981
Young Investigators Award American Trauma Society, 1981
Best Research Paper American College of Chest Physicians, 1981l
Chief Division Cardiac Surgery Beth Israel Medical Center, N.Y.
1979-1980 John Alverdy (Univ Ilinois)
Nutrition with Sheldon, Professor of Surgery
Univ Illinois faculty
1979-1980 James Stone. (Univ Illinois)
Nutrition with Sheldon
Asst Professor Surgery, Stanford
1979-1980 Hoon-Sang Chi. (Yonsei University, Seoul, Korea)
Nutrition with Sheldon
Director Yonsei Medical Center
1979-1980 Christopher Baker (UCSF)
Immunology with Carol Miller Asst Professor, Yale,
Professor and Trauma Chief, North Carolina.
1981-1983 Robert Mackersie (UCSF)
Lung water in shock with Frank Lewis
Asst Professor UCSD, then Professor, Chief Trauma, SFGH
1981-1982 Richard Carmona (UCSF)
Shock with Trunkey
U.S. Surgeon General 2002-2007
1981-1983 Valerij Selivanov
Nutrition with Sheldon
Case Western Reserve faculty
1982-1984 Fred Bongard (UCSF)
Lung water in shock with Frank Lewis
Professor of Surgery, Harbor UCLA Medical Center
1982-1983 John Morris (Vanderbilt)
Shock with Trunkey
Chief Trauma, Vanderbilt.
1983-1984 Louis Ostrow (U.S. Air Force)
Lung water in shock with Frank Lewis
Awards: Residents Research Award ACS, COT, Region IX
ACS Committee on Trauma research award, 1984
Residents Research Award ACS, COT, 1985
Military Surgeon Air Force
1984-1985 Arun Gosain (University of Wisconsin)
Lung water with Frank Lewis
Craniofacial plastic surgeon, University of Wisconsin
1985-1987 Nic Nelken (UCSF)
Lung water with Frank Lewis
Vascular surgeon private practice Los Angeles
185
CHAPTER V
THE FRANK LEWIS YEARS: 1986–1992
Don Trunkey, the chief of Surgery at San Francisco General Hospital
(SFGH), indicated in the spring of 1986 that he would leave at the end of June to
take the position as chair of Surgery at the University of Oregon. At that time,
San Francisco General Hospital (SFGH) had changed markedly from the 1970s.
Mission Emergency—the emergency room that had been run by on-site surgery
residents through its entire existence—now had full-time emergency physicians.
Surgery was now limited to the “east side,” where trauma and surgical problem
cases were admitted. The City-wide ambulance system, which was the first
responder to all major emergencies during this period, was under financial
pressure to maximize its income and was threatened with takeover by the private
sector.
Homicides in San Francisco, which had peaked at 149 in fiscal years
1976-1977—were now down to 103 in fiscal years 1986-1987 (data from the
chief medical examiner). Serious motor vehicle accidents and the associated
blunt trauma had declined, as well. This reduction was probably related to a
number of factors, which included freeway congestion that slowed traffic,
stricter drunk driving laws, and adoption of the requirement for vehicular
restraining devices.
Whereas trauma had previously been the principal motivating force in
the politics of SFGH, AIDS had now taken over the headlines and dictated the
direction of the hospital budget. The City, noted for its liberality, became the
focal point of gay activism. As violence in the city decreased and gay activism
increased, the care of AIDS patients replaced the hospital’s emphasis on trauma.
Under the leadership of Merle Sande, chair of the Department of Medicine at
SFGH, the hospital opened an AIDS clinic in 1983—the first of its kind in the
United States. In August of the same year, a twelve-bed AIDS ward was opened
(Ward 5B, later to move to 5A). This was the first unit in the world dedicated to
the management of AIDS patients. The clinic and ward soon became
international models. The staff of the ward was largely drawn from the gay
community. Many of the nurses who originally worked on the ward died of
AIDS before effective treatment became available in 1996. SFGH leadership in
the care and management of AIDS patients has continued, SFGH consistently
being named the number 1 hospital in the United States for AIDS care by U.S.
News and World Report.
Hospital administration was tempestuous during the last half of the
1980s and the first part of the 1990s. Directors of Public Health and hospital
directors came and went with little notice or impact. There were three different
directors of Public Health and four different hospital directors in the period
1986-1992, for example. This led to gross instability of decisions regarding
budgets and personnel. In 1991, hospital administration finally stabilized with
the appointment of an effective administrator, Richard Cordova.
Administration of the hospital had been complicated by the fact that the
chief administrative officer (CAO) of San Francisco had been Roger Boas, to
whom the director of Public Health had previously reported. After Boas was
186
forced from office as a result of a sex scandal, the City Administration was
restructured, placing the Department of Public Health under the office of the
Mayor. The CAO had been created by a Charter revision in the 1920s and was
intended to immunize several City departments from political influence. In
effect, now what happened was that the Public Health Department was more
heavily politicized and mismanaged than ever before. As an example of this
administrative instability, the hospital had been put on JCAH probation in 1985
and would not receive full three-year accreditation until 1992.
The Nursing Service was also in disarray. Lack of strong leadership,
constant staffing problems, and overwork due to a shortage of nurses nearly led
to a strike in 1988. A strike was averted at the last minute, when the nurses’
union won a new contract that tightened the nurse-to-patient ratio in ward
staffing. The agreement was to stop elective admissions when the nursing census
was down or when the emergency admissions went up. As a result, elective
admissions were effectively at the mercy of nursing staffing. If adequate nursing
staff was not available, elective surgical cases were delayed or cancelled even
more commonly than previously, under a similar 1979 agreement. When budget
freezes occurred, elective surgery was discontinued.
The decision regarding Trunkey’s replacement was not long in coming.
Frank Lewis, the assistant chief of Service under Trunkey, had developed a
distinguished record in research and was recognized as a superb teacher and
surgeon. As such, he was the obvious candidate to succeed Trunkey as chief of
the Surgical Service, and his appointment went through after only a minimal
search by the Search Committee.
THE PROFESSOR
Frank Lewis
Frank Lewis was born on
February 23, 1941, in Willards, a
small town of about 500 persons on
Maryland’s eastern shore where his
father was a general practitioner and
the only doctor within a radius of 20
miles. He attended high school in
Salisbury, Maryland, where he
received an Academic Diploma in
1958. After graduating first in his
class in high school, he was accepted
to both Harvard and Princeton. He
chose Princeton primarily because it
was closer to Virginia, where he had
a girlfriend, but he soon came to
appreciate Princeton for its own sake. He says: “The educational atmosphere
there was outstanding and the talent of both the faculty and the students was
extraordinary. Princeton has a great tradition of putting its best teachers in the
freshman courses, so the quality of teaching in math and physics was
187
unequalled. I gravitated naturally into a physics major, which I had always
enjoyed.”
In l961, he was graduated cum laude in Physics, but he decided to study
medicine rather than physics because he believed it would offer more freedom in
future lifestyle choices. He then attended the University of Maryland Medical
School, where he came under the influence of “a charismatic professor of
Medicine, Ted Woodward,” and he decided to become an internist. He planned
to intern elsewhere and then return to the University of Maryland for a medical
residency. This plan lasted six months into his mixed medical-surgical
internship at SFGH.
When he began his surgical rotation, Lewis came in contact with
surgical residents and was amazed at the competence, assurance, and seeming
mastery of patient care that they exhibited. John Baldwin was chief resident
during most of his surgical rotations. In particular, Baldwin's seemingly
comprehensive clinical skills in assessing patients, making quick decisions, and
carrying out technical surgical procedures exceeded the abilities of anything
Lewis had seen in the medical resident ranks. In addition, he was influenced by
Bill Silen, chief of Surgery at SFGH at that time. “The talent level was pretty
high and, more importantly, I found that the nature of surgical care was more
appropriate to my personality—see a problem, do something about it, and see
the results immediately.” Gone was the idea to become an internist. He decided
to become a surgeon and was recommended by Silen for the UCSF surgical
program.
Lewis was accepted to UCSF, but had to wait until the following year
to begin his residency because all slots for the current year had been filled. This
left him with a year of nothing to do. He had always been interested in how
things worked and wanted to do research. The obvious thing to do, it seemed to
him, was to “marry medicine and physics” and get some more training. He
chose the Donner Laboratory at UC Berkeley—the “home of medical physics.”
This was the place where isotopes were invented and first used in medicine by
John Lawrence M.D., brother of Ernest Lawrence, the inventor of the cyclotron.
He was accepted into the Ph.D. program at the Berkeley Donner Lab and
worked there during the l966-1967 academic year. That year, plus a second year,
l969-1970—his elective residency year, when he returned to Berkeley to finish
his Ph.D. work—gave him the knowledge and background for research he
would do later, first in extracorporeal membrane oxygenation (ECMO) and then
later in cardiopulmonary physiology. In particular, this work included study of
the alterations in heart and lung function as affected by crystalloids and colloids
following trauma and sepsis.
During his senior and chief resident years, Lewis became acquainted
with Don Hill at Stanford Presbyterian Hospital, who was just beginning to use a
membrane oxygenator to support patients with end-stage respiratory failure.
Branson, a British engineer, had built the oxygenator—he is the same Branson
who, during World War I, modified the synchronized machine gun, originally
invented on the Continent, so that it could fire through an airplane propeller
without cutting the propeller off. The oxygenator was the first workable
membrane oxygenator that was practical for use with patients. It was a huge
monstrosity and was very complicated to operate, but it worked. Unfortunately it
wasn’t very successful in treating the acute respiratory distress syndrome
188
(ARDS). Lewis and Hill used it for a few patients at SFGH, but it did not
reverse the disease.
When Lewis finished his surgical residency, SFGH looked like the
place to begin his academic career. He wanted to do further research in ECMO,
and SFGH was a good choice because it had plenty of trauma and sepsis cases,
and therefore ARDS cases. Because of Lewis’s interest in ECMO, Blaisdell had
encouraged him to apply for an NIH grant to participate in a multicenter study.
He received $550,000 for a study of ECMO support of patients with ARDS,
which included money for his salary. Coming out of his residency with a
$550,000 research grant was “very heady,” he says.
An outgrowth of his interest in ECMO became an interest in critical
care. As improvements in the management of ARDS developed—particularly
the utilization of positive end expiratory pressure—deaths in the acute phase of
respiratory failure became a rarity, and the use of ECMO no longer had much to
offer. However, Lewis became fascinated with the pathophysiology of ARDS.
He recognized this as a microvascular occlusive and capillary permeability
problem, not high-pressure pulmonary edema due to overenthusiastic
administration of fluids, as many speculated. This realization led him to an
interest in measuring lung water and determining the role of crystalloids versus
colloids in treating patients with “sick lungs.”
Lewis says, “Four men have had great influence on me and have
provided qualities which I consciously and unconsciously emulate.
“The first was Ted Woodward, at Maryland, who was a consummate
internist and clinician, a remarkable Socratic teacher, and a world’s expert on
infectious diseases. Both his teaching technique and his clinical acumen were
outstanding and were models that I have always thought were close to ideal.
“The second was an extraordinary man, Ephraim Lisansky—Boarded
in both psychiatry and internal medicine—who specialized in psychosomatic
diseases. He taught us as first-year medical students, and the purpose of his
sessions was to demonstrate how to interview and interact with patients. On
Saturday mornings, he would interview patients with complex medical and
psychosomatic problems in a lecture hall in front of 100 medical students and
explore the most intimate details of their problems. He had a unique ability to
'connect' with patients and to relate to them on a meaningful personal level
through the interview process. I’m sure it has greatly influenced how I deal with
patients throughout my medical career.
“The third was J. Engelbert Dunphy, chair of the Department of
Surgery at UCSF from 1964-1976. His conduct of M&M Rounds at UC was one
of the most entertaining and valuable teaching experiences I’ve ever seen. He
had a repertoire of moods and responses, from anger to joviality to incredulity
and he could always tell a story or joke at the appropriate time to make a point
or lighten the circumstance. Most of all was the fact that he emphasized that
surgery was a game of precision and detail; that there were right and wrong
ways to do things, and that surgical principles were the most important thing to
learn and apply. Overriding everything was the necessity for absolute honesty in
recognizing and confronting the problem, no matter how hard it might be. It is
unfortunate that Dunphy’s M&M sessions were not videotaped—they were
189
considered, by residents and faculty, to be the premier teaching event of the UC
residency. Dunphy combined the talents of the master surgeon and Irish
politician. He built the strongest Department of Surgery in the country at the
time because of his ability to motivate everyone to their greatest potential.
“The fourth, and overall the most important one, was Bill Blaisdell,
who was influential in my training. From him I learned that assiduous attention
to the patient in the best possible way is your absolute responsibility, and that
you should be totally honest about adverse outcomes, complications, and their
causes. Later, when I became chief, I tried to inculcate these ethics in residents
and students. Blaisdell had a superb understanding of surgical principles and
great surgical judgment, as well as superb insight into surgical physiology. He
was the first person in the United States to correctly identify the cause of acute
respiratory failure to be microvascular in origin, and he has never been
appropriately credited for this.”
Frank Lewis was a superb conversationalist, well versed in most issues
and always sure of his facts. On occasion, he could be impish. He was an expert
on wines, restaurants, and the San Francisco peninsula real estate market. He
loved cars, including a powerful Aston Martin—an English make with a big
engine and no brakes, which occasionally he would drive from his Hillsborough
residence to SFGH. Fortunately, the freeways were less crowded in those days
and he survived the car.
He was intellectually very confident. He was hardly ever in doubt about
any problem or situation that he had any degree of knowledge about. One of his
favorite statements during the course of a conversation—and sometimes
designed to bring the issue to closure—was, “in point of fact….” At his 60th
birthday celebration, his high school classmates remembered him with affection
as the “smartest kid on Maryland’s Eastern Shore.” One of his laboratory
fellows, who also trained in general and cardiac surgery at UCSF, says, “There
was no doubt that Frank Lewis was the brightest of all the talented surgical
attendings.”
ADMINISTRATIVE & PERSONAL STYLE
Lewis’s leadership style differed from his predecessor. Trunkey’s was
looser, Lewis’s more structured. Trunkey delegated, while Lewis—who had a
great talent for detail and was extremely bright and self confident—was
comfortable making decisions on his own and consequently made many
determinations without consulting staff. He was characterized by one of the
senior members of the staff as doing “a very good job and running a tight ship.”
Lewis traveled, although nowhere near to the extent that Trunkey did.
Lewis worked very hard and kept long hours. A member of his staff
characterized this, saying, “The door to his office was open and he was working
when I left in the evening and when I returned in the morning. It made me feel a
little guilty.”
Lewis says, “It would be erroneous to say that, as chief, I had any kind
of overall plan for managing the program.” His goal was to turn out safe
190
surgeons, and he believed that residents should be taught the surgical principles
that underlie safe surgery and, at the most, one additional way of doing things.
He rejected the idea that it was educationally valuable for residents to see things
done in multiple ways—a concept not always in concert with residents’ views.
Later, when residents were more experienced, they could try other methods.
Lewis was very suspicious of dogma and brought intellectual rigor and
skepticism to medical concepts. He preached to medical students and residents
that they should never accept medical “authority” in anything, but should
challenge what they were taught and ask for data and logical proof before
accepting something.
Initially, relations with the staff in the Department were very collegial.
One of the staff said that there was “an incredible spirit of camaraderie and there
were a lot of projects going on to change the Department and to modernize it.”
Later, as financial issues escalated, laboratory research continued to lag and—as
no new research grants were obtained, with the exception of Lewis’s grant from
the Centers for Disease Control and Prevention (CDC)—morale began to sag
and personality problems developed. Relationships with the University
progressively soured. The two people in the Department capable of doing
laboratory research felt that they had not been given enough support by Lewis.
Without trying to analyze all the reasons, it is fair to say that, by the time Lewis
left, morale in the Department was low.
THE STAFF
When Lewis was formally appointed chief, his staff consisted of eight
general surgeons—three full professors and five assistant professors: Lewis, Jan
Horn, Bob Lim, Jim Macho, Bob Markison, Bill Schecter, and Art Thomas.
Mike Hickey was the eighth general surgeon on the staff. He had been hired to
run the total parenteral nutrition (TPN)-nutritional support service and worked in
the ER, but did not take surgical call. (For the biographies of Lim, Thomas,
Markison and Schecter, see the previous chapters.)
Jan Horn
Jan Horn was recruited by Don
Trunkey, with Lewis's agreement, just before
Trunkey left for Oregon. Horn had trained at
New York University Medical Center in New
York City. After completion of his residency in
l982, he had come to SFGH to work as a
research fellow on complement activity with Ira
Goldstein. His first paper with Goldstein, on
lysosome secretion, was published in 1974,
while Horn was a medical student. While
working with Goldstein between l982-1985, he
began to take call in the emergency room and in
the Surgery Department. His research looked
promising to both Trunkey and Lewis, and Horn
indicated that he wanted to stay on at SFGH. Following his appointment in
1986, Trunkey immediately named him director of the Burn Unit.
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At the time of his appointment, Horn was well versed in the molecular
biology of the inflammatory response syndrome and leukocyte function and was
well prepared for laboratory and clinical research.
Horn remains at SFGH and is professor of Clinical Surgery at UCSF.
During Lewis’s tenure, Horn’s research interest consisted of exploring the
effects of heat stress on the immunologic function of human neutrophils. In that
period, he was co-investigator on a Public Health Service Academic Training
Grant in Trauma and Burns, principal investigator of an Academic Senate
Research Award from UC, and principal investigator of a UCSF Dean’s
Research Evaluation and Allocation Committee (REAC) Award.
He is considered an outstanding teacher and mentor by students and
residents and has been cited several times for his teaching excellence.
James Macho
Jim Macho was also recruited by
Trunkey during his last days at SFGH, but
technically he was appointed by Lewis. Macho
describes his appointment this way: “During
the last several months of my training at
UCSF, I had been traveling around the country
and had interviewed at Yale, Chicago,
Tennessee, and Brooklyn. I went to Trunkey
to talk about the different jobs and he said,
'Have you been offered a job here by Frank?' I
said no. Trunkey thought I should stay on at
the General. Within three or four days, Frank
called me into his office and offered me a job,
which I accepted.”
At the suggestion of Tony Meyer, Macho had done a critical care
fellowship at SFGH and Moffitt Hospital during his laboratory year. When he
signed on at SFGH, he was interested in doing research in sepsis, bacterial
translocation, and multiple organ failure and was assured by Lewis that he
would have the time and the funds for laboratory research.
Although Macho’s basic science research never got off the ground
primarily due to lack of funding and protected time, he made significant
contributions to the literature by describing the use of skin staplers for
cardiorrhaphy after penetrating injuries to the heart and outlining the indications
for emergency room thoracotomy after a review of a large number of cases at
SFGH. Jim was facile with computers and helped Lewis with the
computerization of the Department. Macho left SFGH in 1991, going to the
Mount Zion campus of UCSF as chief of Critical Care. In 2002 he went into
private practice.
Mary Margaret Knudson
Peggy Knudson joined the faculty July 1, 1989. She had attended the
University of Michigan Medical School and trained at Beth Israel Hospital in
Boston and at the University of Michigan, where she was chief resident in
surgery during 1981-1982. In 1982-1983, she took a fellowship in pediatric
192
surgery at Stanford and, at the time of her
recruitment to SFGH, was assistant clinical
professor at Stanford and associate director of
Trauma Services at Stanford University Medical
Center.
After arriving at SFGH, she rapidly
became a confidante of Lewis as she pursued her
career in Trauma. She quickly focused on two
areas of trauma care. These were the
nonoperative management of liver and spleen
injuries and thromboembolism after trauma. She
organized retrospective and later prospective
studies in these fields. Because of her interest in
thromboembolism, she began to apply ultrasound to its diagnosis in the trauma
patient.
She helped write the initial San Francisco Injury Center grant, awarded
by the CDC, which was approved before Lewis left. This grant has received
repeated renewals with Knudson as the principal investigator.
In 2001, Knudson was promoted to professor of Surgery at UCSF and
she remains at SFGH, where she has developed a superb clinical and academic
record. She is known nationally for her extensive publications on
thromboembolism and for her work in professional organizations.
Robert C. Mackersie
Bob Mackersie joined the Surgery
Department in October 1991, nine months
before Lewis left for Henry Ford Hospital.
Although Mackersie was in the Department
for only a short time while Lewis was chief,
they have a history together that goes back to
the 1970s.
Mackersie had received a Bachelor of
Science degree in Mechanical Engineering at
UC Berkeley in l973, and then had a graduate
year in the Department of Engineering Science
at UC Berkeley in l973-1974. Lewis learned
that Mackersie, who in 1975 was in his first
year of medical school, had expertise in
computers. Lewis recruited him that summer
to do computer programming and some additional research work in the intensive
care unit at SFGH. The following summer, Mackersie again worked with Lewis.
Greatly influenced by Lewis, Mackersie decided to become a surgeon. When he
was graduated from Michigan, he took his residency training at UCSF. His
research years, from 1981-1983, were spent in Lewis’s laboratory, where he
studied pulmonary physiology and lung water.
Mackersie, after completing his residency in 1985, joined the Trauma
Program at UC San Diego, working with Steve Shackford and Brent Eastman.
He remained there until he was recruited back to SFGH by Lewis in October
1991 as chief of the Trauma Service.
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In 2007, Mackersie is the principal project investigator for the Trauma,
Lung Injury Section of the San Francisco Injury Center CDC grant. He is also
principal investigator for the Academic Fellowship Grant in Violence
Prevention, sponsored by the California Wellness Foundation.
Arthur Thomas
Art Thomas remained a favorite of the residents, who enjoyed his
informal teaching sessions and the exposure to thoracic surgery that he provided.
He remained on the staff until he retired in 2002. At that time, a
boisterous party was held for him at Trader Vic’s in Emeryville, with many of
his residents and UCSF faculty participating. (For Thomas’s biography, see
Chapter III.)
Robert Markison
Bob Markison’s biography has previously been given. Bob continued
his special interest in hand surgery and made the decision to enter private
practice several years into Lewis’s tenure at SFGH. (For Markison’s biography,
see Chapter IV.)
Michael Hickey
Mike Hickey completed his training in General
Surgery at the University of Texas, Houston, under Stanley
Dudrick, the founder of intravenous nutrition. He then went
into private practice for several years before joining the
faculty at SFGH. In addition to his work in the emergency
room, Mike reinvigorated the Nutritional Support Service,
which had been established by George Sheldon in the early
1970s. Hickey continued to run the Nutrition Support service and attend in
Mission Emergency until 1999, when he made the decision to return to Texas
and enter private practice.
Robert Lim
Bob Lim’s biography appears earlier in this volume (see Chapter III),
but he was such an integral part of the service that he deserves additional
emphasis. He did most of the elective vascular surgery and much of the
technically demanding surgery, such as parathyroidectomies. He pioneered in
vascular access surgery for dialysis and remained interested in this field, which
was so often frustrating and repetitive because of thrombosis. His interest and
devotion was such that the nephrologists provided him special funding that he
used to support his research. The nephrologists believed he was the most skilled
surgeon they had encountered in the UC system, and they were not interested in
having anyone else do their cases.
Lim also had a large referral practice from the Chinese community,
many of whom were patients with liver tumors, which seemed epidemic in
recent immigrants from China. Because of his surgical skill, he enjoyed nearly a
monopoly on tumor resectional surgery in the Chinese community.
His departure in 1989 to go to Moffitt Hospital at UCSF was a
significant loss to the SFGH Surgical Service. He has been described as “the
heart and soul of the County program.” In addition, when he left, he took a
University FTE with him, leaving the Department only one—Dr. Lewis’s. His
194
leaving occurred in part because of a dispute with Lewis over the funds that Lim
was receiving from the Department of Medicine. Because of budgetary
problems, Lewis insisted that the funds he received from Medicine be turned
over to the Surgery Department. This left Lim with two alternatives, neither of
which he liked: either continue to do all the vascular access procedures but give
up his research funding from Medicine, or insist that the other members of the
Department share the chore with him. He resolved the issue by moving to UC
when he was offered the chance perform the liver resectional surgery for the
University Transplantation Service.
After being treated for a malignancy, of which there has been no
evidence of recurrence, Lim retired in 2000. Lim was universally loved by all
those who came in contact with him, from janitor to hospital director.
SPECIALTY SURGICAL STAFF MEMBERS
Vascular Surgery
Loie Sauer, who had a vascular fellowship at UCSF, was the vascular
attending for two years (1989-1991). She went into private practice in Santa
Rosa, where she is married to a vintner and has a wonderful family.
Nicholas Nelken, another UCSF graduate, was recruited as a general
and vascular Surgeon in 1991. He had done four years of successful basic
science research at the CVRI just before he came to SFGH, where he remained
for thee years. He appeared to have excellent potential as an academic surgeon,
but was torn between the laboratory and clinical practice. He eventually opted
for private practice.
Plastic Surgery
Ron Barton was chief of Plastic and Reconstructive Surgery when
Lewis became chief of Surgery in 1986. Barton left in 1988 to become
professor at Vanderbilt and chief of Plastic Surgery at the VA Hospital in
Nashville, Tennessee.
Phil Trabulsy replaced Barton and then moved to the University of
Vermont in 1994. He was a spectacular reconstructive surgeon. Unfortunately
he developed occupationally acquired HCV infection shortly after arriving in
Vermont (probably acquired at SFGH) and elected to withdraw from operative
surgical practice. He is currently practicing sports medicine at the University of
Vermont
Urology
Jack McAninch, appointed chief of Urology at SFGH in 1977,
remained at SFGH as chief of Urology and professor of Surgery at UCSF. He
has had a very distinguished career, has published over three hundred papers and
book chapters, and is a Regent of the American College of Surgeons.
Neurosurgery
Lawrence Pitts continued as chief of Neurosurgery at SFGH during
this entire period. He was a graduate of the UCSF training program, served as
195
assistant chief of Neurosurgery at SFGH under Julian Hoff, and succeeded Hoff
as chief in 1979, when Hoff moved to the University of Michigan. Pitts
continued as chief of Neurosurgery, only giving up his position at SFGH in 1995
when his practice at UC was occupying him completely.
Orthopedics
Lorraine Day was chief of Orthopedics from 1980-1988. On
completion of her residency at UCSF in 1977, she served as assistant chief under
Ted Bovill after Michael Chapman moved to UC Davis. When Bovill retired in
1980, she became chief of service. She was extremely active in pointing out the
dangers that AIDS presented for surgeons and promoted the use of a “space
suit” for operations on AIDS patients. She married a movie producer, moved to
Palm Springs, and retired from the practice of surgery in 1989. Guy Paiement
was appointed chief of Orthopedics in 1989, following Day's retirement.
Otolaryngology
Thomas Wild was chief of ENT from 1979-1989. He was succeeded
by Thomas Tami who served from 1989-1992.
STAFF ORGANIZATION
Lewis continued the Trunkey model of staff organization. The daily
census for the entire service was normally between 80 and 110 patients. The
staff provided full coverage for five Surgical Services: Trauma, Elective,
Extremity, Hand, and Plastic. This included all operations on these services as
well. The Surgical Service under Lewis admitted approximately 6,000 inpatients
yearly—2,400 of these to the Trauma Service—and saw roughly 20,000
outpatient visits per year.
Two attendings covered the trauma service by alternating nights and
rounding on their respective half of the service each day. As there were two
resident trauma teams, this worked well. A third attending covered the
Extremity-Elective Service, which included patients needing hand surgery.
Schecter and Markison did most of the hand cases with junior residents.
Individual attendings covered the elective surgical cases they generated from
their personal clinics and ward consultations. The Trauma attending generally
took call at home, with the exception of Horn, who lived in Redwood City and
slept at SFGH when he was on call.
When Peggy Knudsen joined the staff, she needed a different call
schedule for personal family reasons, and the staff went to a monthly-shared
schedule with each attending doing a few nights of call. Initially there were two
chief residents at SFGH, but in the 1990s the number was reduced to one.
This system meant that, each month, only three attendings would be
busy clinically, leaving their non-clinic days relatively free to write or do
research.
196
CLINICS
In addition to ward and operative responsibilities, the faculty had
clinics to cover. There were twelve half-day surgical clinics each week. The
clinics consisted of General Surgery, Trauma, Vascular, and Proctology. The
members of the staff covered theses clinics in rotation. In the early 1990s, Peggy
Knudsen created a separate, multidisciplinary Breast Clinic, where consultations
from oncology, radiation therapy, and plastic surgery were available.
FINANCES
When Lewis assumed responsibility for the Department in 1986, his
chief priority was obtaining and maintaining fiscal solvency, which he found
precarious. The Surgery Department was recovering from embezzlement (see
Chapter IV) and was just finishing paying off a $500,000 computer debt. Adding
to the problem of making ends meet was the loss of University FTE salary
support, so that most of the salary support for the surgical staff now, of
necessity, came from patient care. His second priority was getting the
Department’s research laboratories re-established and getting back into basic
research. Lewis succeeded in obtaining fiscal solvency by means of an
innovative computer program, which tracked patients and verified attending
involvement through daily progress notes. This program improved the ability to
collect fees from third-party payers.
With Trunkey’s departure, the Department was down to two University
FTEs Lewis’s and Bob Lim’s—and one City FTE. In l989, when Lim moved to
the UCSF campus, the Department lost another FTE. Major grant support no
longer existed to help support staff salaries, and research money was not
generated to any significant degree. The Trauma Center Program Project Grant,
which had first been awarded in l969, had not been renewed in l981. Lewis’s
NIH grant for the study of lung water and pulmonary capillary permeability had
ended in l985. The primary source of funds to support faculty now came from
clinical care.
Because income generation had to come from patient care, more faculty
time had to be devoted to clinical work and the paperwork necessary to secure
payment from third-party payers. Most of the patients at SFGH were Medicare,
MediCal, or “no pay” patients. To ensure recovery of fees from Medicare,
MediCal, and other third-party payers, Lewis’s computer-generated system of
documentation became essential.
Lewis purchased computers for everyone who did not have one,
established an office network, and wrote a database that could be used for
multiple purposes. The program was called Advanced Revelation—a computer
program, not a religious cult—and it differed in design from most others. He
was assisted in developing the program by Jim Proctor, who was an expert in
this program and all aspects of computers. The system permitted the tracking of
patients, acted as a trauma registry, and maintained morbidity and mortality
statistics. It facilitated keeping attendings' progress notes current and complete,
and thus allowed accurate, well-documented billing that resulted in prompt
reimbursement. One of the unexpected consequences of the outstanding
documentation that this system provided—typed progress notes by attendings on
all patients on the Surgical Services in the charts six days each week—was that
197
there were no malpractice awards involving the Surgery Department during
these years, despite thousands of cases and patients.
The reason this system was so important was the bias of MediCal,
Medicare, and most other payers, that most patients in a county hospital were
cared for by residents. Therefore, if attendings were to get paid, they had to
show—by daily progress notes and by operative notes—that they were indeed in
charge. The operative notes were easily done. The daily progress notes were
made by attendings at the bedside through hand-held recorders and were
subsequently transcribed and pasted into the patient’s chart. This system resulted
in superb documentation, with the result that the attendings' billings were
promptly paid. More importantly, attending oversight was actually there on a
daily basis and resulted in consistent patient management. This system is still in
place in the Surgery Department and—in addition to billing functions—allows
for the tracking of individual surgeons’ morbidity and mortality statistics.
Sophie Mitchell directed billing during this time. Carol Shagoury was
the Trauma Nurse Coordinator who maintained the statistics on trauma
complications. They both became very proficient in the use of the program.
Another problem, which constantly affected the hospital, was the San
Francisco City administration. Relations with City Hall “waxed and waned,
depending on the hospital administrator and the director of Public Health. There
were no major disagreements or crises during this period, and the City subsidy
for the hospital amounted to $30 million to $40 million per year, which was
actually pretty good for the time.”
Lewis’s biggest political problem was the UCSF administration.
Relations with the Dean’s office and the UC Department of Surgery were distant
and sometimes tense. Lewis characterized them as “reasonably cordial, but with
little interchange, either professionally or financially.” Haile Debas, the new
chair and professor of Surgery at UCSF, and Lewis did not always see eye to
eye. There were disagreements over the allotment of FTEs. Lewis readily
expressed the belief that the FTE allotment to his Department was unfair and
heavily favored the main campus, although the student-resident teaching load
was approximately equal for the two sites. In addition, the fact that the SFGH
Department was required to be essentially self supporting, through patient care,
left little time for clinical research. He felt strongly that this was further
argument for a more equitable distribution of FTEs. The insurance coverage of
patients at UCSF’s Moffitt Hospital was between 80% and 90%, whereas at
SFGH it was 20% to 30%; thus the ability of the faculty to be self-supporting
was much easier at Moffitt.
Lewis also took issue with the distribution of overhead funds from
research grants—an issue that did not affect just his Department. At the time, it
was estimated that SFGH received approximately $25 million yearly in grants,
and this generated $6 million to $7 million in indirect cost reimbursement—yet
the support allotted to SFGH was less than 10% of that amount. Higher
allocation of the overhead monies would have allowed additional development
of facilities for clinical and laboratory investigation.
198
As the result of his inability to obtain money to upgrade his research
space, Lewis spent $120,000 of his Department’s funds for renovations of the
second floor of Building 1—the old operating rooms—to try to prepare the
space for laboratories. This was a resource he could have used to provide seed
money for research by his junior staff.
RESEARCH
Although clinical research continued during Lewis’s tenure, laboratory
research—which had all but disappeared during Trunkey’s term—continued to
suffer. Lewis had inherited a staff, which—with the exceptions of Jan Horn and
Bob Lim—was not laboratory research oriented. Lim was doing platelet
research that was supported by money from the Department of Medicine in
exchange for his work in performing vascular access procedures for dialysis
patients. This was a demanding chore that other members of the staff were not
fond of doing.
Unfortunately, the other member of the staff interested in laboratory
research, Jan Horn, had not been successful in obtaining a major grant that
would help support his salary.
However, Lewis secured a substantial grant from the Centers for
Disease Control and Prevention (CDC) to study the epidemiology of trauma in
l989 and a grant from Genentech to investigate the mechanisms of capillary
permeability increase in acute respiratory distress syndrome (ARDS). Lewis’s
major interests were in cardiopulmonary physiology and the changes that occur
in trauma, sepsis, and resuscitation. Lewis expressed regret that he had not
written nearly enough or been able to do enough research or obtain grant support
to prove most of his concepts.
Almost all of Lewis’s research work was done before he became chief.
He had clearly shown how to determine lung water accurately, but just what was
happening in the capillaries to cause increased permeability—and what, if
anything, could be done about it—were still unsolved problems.
His failure to mentor junior faculty and direct them toward laboratory
research probably relates to his own administrative load, the Department’s
financial problems, a faculty who were not oriented toward research, and the
necessity for the faculty to devote more time to clinical matters to generate
clinical income.
Several clinical contributions were made by the faculty. A discovery by
Jim Macho was serendipitous. During an experiment on a sheep, in which the
thoracic duct was cannulated and a conduit placed in the left atrium, the fourthyear medical student who was assisting Macho, took the Satinsky clamp off the
atrium before he had placed a stitch. The field immediately filled with blood.
Macho grabbed a skin staple gun and put a few staples in the atrium, which
produced complete hemostasis. Shortly thereafter, a patient came into the
emergency room (ER) with three stab wounds of the heart. Macho happened to
be in the ER and immediately solved this difficult problem by stapling the three
wounds. The bleeding stopped, and the patient survived and did well. This
technique was subsequently published in the Journal of Trauma and has been
adapted by many others as a means of controlling cardiac hemorrhage.
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Another contribution to the literature helped define the criteria for ER
thoracotomies. In the late 1970s, Baker and Trunkey published a study showing
that the survival rate for ER thoracotomies was 20%. A decade later, resident
Peter Lorenz, working with Schecter and Macho, looked at ER thoracotomies
between 1980-1992 and found that the overall survival rate had fallen to 13%.
When efforts were made to explain the decline, it turned out that patients who
had shown no sign of life in the field were being operated upon. When these
patients were excluded, the survival rate was 19.5%. When they came to the ER
alive, those patients who had cardiac arrest had a survival rate as high as 70%.
This modified enthusiasm for emergency thoracotomy, a risky procedure in the
era of AIDS.
Peggy Knudson helped write the initial San Francisco Injury Center grant
proposal to the CDC, which was approved for funding two years before Lewis
left. This grant has received repeated renewals, with Knudson as the principal
investigator. It is one of ten Injury Centers funded nationally by the CDC. The
grant focuses on the use of tissue-oxygen monitoring during shock and
resuscitation, secondary brain insults after head injury, ultrasound use in trauma,
prevention of pediatric post-traumatic stress disorders, and injury prevention.
This grant received its most recent renewal in August 2001 in the amount of
$4,527,500 for a five-year period. In addition, Knudson also received a grant
from the San Francisco Department of Public Health for a pediatric injury
surveillance system.
MEDICAL STUDENTS
Early in Lewis’s term, the method of teaching third-year medical
students in all three hospitals changed, shifting from didactic lectures to
interactive seminars centered on specific cases representative of different
surgical illnesses. The final examination was also changed to give more weight
to clinical performance during the clerkship.
The student teaching loads at SFGH and the main UCSF campus were
roughly comparable, and at SFGH, teaching was shared equally by all members
of the staff. The teaching of medical students began at the second-year level,
with an eight-week period of physical diagnosis related to surgical problems. At
the third-year level, there was a didactic surgical clerkship in which eight
students were assigned to SFGH for eight weeks. This course was continuous, so
that a total of 48 students were taught by the surgeons at SFGH each year.
At the fourth-year level, there were acting internships for four weeks on
the five clinical services (Trauma, Elective, Extremity, Hand, and Plastic
Surgery). Approximately 70 students rotated through them each year—the
Trauma Service being the most popular.
SURGICAL RESIDENCY
When Lewis became chief, the resident staff consisted of assignments
at the various postgraduate years (PGYs) of the following one PGY-7 (Plastic
Surgery), two PGY-6 (chief residents), two PGY-5 (senior residents), two PGY3 (Emergency Department), two PGY-2 (one assigned to orthopedics), and six
PGY-1 (interns). In addition, most of the time, two PGY-3 general surgical
residents from outside programs that did not have a trauma program, rotated
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through the Trauma Service—San Francisco Kaiser, Oakland Kaiser, Letterman,
and Mount Zion Hospitals, Santa Barbara Cottage Hospital, and Boston‘s Beth
Israel Hospital.
The Services were organized as follows: There was one chief resident
on the Trauma Service and one chief resident on the Elective-Extremity Service.
The chief resident spent two months on each service, so that every year, six
chief residents spent two months each on the two services. The chief resident on
the Trauma Service spent his or her entire two months in the hospital. A former
chief resident, now living in Europe, commented on the high work ethic in the
United States and wondered if he would have gotten time off if his second son
had been born while he was on the Trauma Service. The boy was born two days
after his Trauma rotation ended.
The Trauma Service, in addition to the chief resident, had two teams,
each composed of one senior resident, one junior resident, and two interns.
The Elective-Extremity Service had one chief resident, one junior
resident, and two interns. As surgical demands changed over the years, the
composition of the resident staff would be altered.
Residents’ training was through bedside and operating-room contact
and through conferences. There were ten hours of scheduled teaching
conferences each week. Soon after his arrival, Bob Mackersie instituted
conferences using videotapes of resuscitations in the ER, which greatly
improved their efficiency and effectiveness.
SURGICAL PROCEDURES
The management of AIDS and HIV-positive patients was the most
controversial surgical issue during Lewis’s tenure. During this period, AIDS was
becoming better understood, including how the disease was caused, how it was
spread, how to manage patients, and how to prevent infection of health care
workers. The consistent moral imperative of the Surgical Service during both
Trunkey’s and Lewis’s tenure was that the surgeons were committed to the care
of AIDS patients and would do whatever was necessary to provide optimal
operative care.
Bill Schecter played a major leadership role and did much to counter
the negative influence being provided by the chief of Orthopedics, who
advocated non-operative management of AIDS patients. Schecter demonstrated
that, if one used reasonable precautions and added protection against cuts and
needle sticks by double gloving, the risk was minimal. Schecter developed a
special routine for handling and passing sharps. He introduced non-wettable
gowns and boots with leggings, both in the ER and the operating room.
The principal operative procedures directly related to AIDS consisted
of lung biopsies to obtain cultures and verify the agent responsible for
respiratory failure, biopsies of enlarged nodes, removal of skin lesions, and
treatment of perianal condylomata.
Imaging techniques, applied more and more frequently in the
assessment of trauma cases in the ER, resulted in a significant drop in the
number of trauma laparotomies. Although CT imaging resulted in fewer
operations for benign splenic trauma, splenic bleeding still remained a common
indication for operative intervention. The junior staff tended to favor
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splenorrhaphies over splenectomy whenever possible, while the senior staff
tended to utilize splenectomy as the treatment of choice.
Interventional radiology was used more frequently in assessing
bleeding and lent itself to the control of hemorrhage by non-operative means,
using stents and embolic occlusion.
Thoracic surgery, under Art Thomas’s direction, consisted of
lobectomies and, more rarely, pneumonectomies for cancer, esophagectomy for
cancer, and an occasional thymoma resection.
Lim was referred a large number of patients with liver tumors, and
partial hepatectomies were on the schedule monthly. Lim also performed most
of the endocrine procedures and the difficult vascular reconstructive procedures,
as well as numerous vascular access procedures required to support the dialysis
program. After he left to work at the Parnassus campus, Horn and Schecter
temporarily covered this demanding group of patients in the intervals when a
vascular surgeon was not available.
Frank Lewis and Bill Schecter supervised most of the general surgery
procedures, which included hernia, biliary, bowel, and gastric surgery. Hand
surgery, although shared with orthopedics, was supervised by Bill Schecter and
Bob Markison, who had formal hand training with Eugene Kilgore’s group. Jim
Macho and Jan Horn covered breast surgery until Peggy Knudson’s arrival,
when she took over supervision of this discipline.
Other developments had occurred or were looming that would change
surgical practice. In 1983, the H. pylori bacterium was identified as the
causative agent for most peptic ulcer disease, and it was shown that peptic ulcers
could be treated with antibiotics. H-2 blockers and proton pump inhibitors had
come on the scene and were effective in treating ulcer disease and reflux
esophagitis. Most bleeding ulcers could be treated endoscopically or by
embolization. The net effect was that, except for simple closure of a perforated
ulcer, peptic ulcer surgery disappeared. Few residents had any experience with
vagotomies.
The surgical treatment of bleeding varices was abandoned in favor of
variceal sclerosants and percutaneous transhepatic portal-hepatic vein
decompression. Radiological interventionists began to play a more important
role in treating other causes of GI bleeding utilizing embolic treatment. They
also began to play a major role in percutaneous drainage of abdominal
abscesses, so that surgical interventions for these abdominal problems were
needed less frequently.
In 1984, the first laparoscopic (lap) cholecystectomy was done in the United
States. After initial academic skepticism, there was a rush to learn and perfect
the technique. Jan Horn took a laparoscopy course from McKernan in Georgia
operating on pigs in 1990, and then practiced on sheep. With Leonard Schlain
and Jonathan Leichtling as proctors, he performed the first successful
laparoscopic cholecystectomy in the UC system. Larry Way at Moffitt Hospital
followed shortly thereafter. Horn had to make do with the instruments currently
available, which were pieced together from those used by ENT, Urology, and
Gynecology. After he had done about 25 cases, he began to let the chief
residents perform the operations, in addition to educating them using training
modules. In order to advance laparoscopy, Horn was forced to beg, borrow, and
purchase equipment on his own, long before the hospital would accept the
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equipment as appropriate budget items. An additional obstacle was Lewis’
initially negative opinion regarding the future of these procedures.
Once the most of the staff had received training in laparoscopic biliary
surgery under Horn’s leadership, they began expanding the technique to other
procedures, such as endoscopic anti-reflux procedures, appendectomy,
herniorrhaphy and splenectomy.
Schecter, Mackersie, and Thomas all had endoscopic surgery training.
Horn assisted Thomas in performing the first thorascopic procedures until
Thomas felt comfortable performing them on his own. Trauma procedures
remained the exception, as the trauma surgeons continued to favor open
procedures over endoscopic approaches.
There continued to be a constant struggle to obtain adequate equipment.
Much of the equipment necessary to advance the endoscopic techniques was
either donated or loaned by the representatives of instrument vendors.
THE INTENSIVE CARE UNIT
The intensive care unit (ICU) was a multidisciplinary unit. The Medical Service
had a respiratory ICU and a coronary ICU, so the main ICU was dominated by
surgical cases. After the Burn Unit was closed, the number of patients with
major burns decreased. Those remaining were admitted to a separate, isolated
area of the ICU. Major trauma made up the major proportion of the cases
occupying the unit.
The chief of the unit continued to be anesthesiologist Richard
Schlobohm. He supervised a multidisciplinary team of surgeons, internists, and
anesthesia residents whose primary responsibility was respiratory care and painsedation management. Macho and Lewis were the primary surgical attendings
covering the ICU. The surgeons retained primary responsibility for their patients
and rounded daily.
The biggest problem for the Surgical Service was the continued
shortage of ICU beds, which was a hold-over from the Trunkey period. It was
necessary to move patients out of the ICU as fast as possible, because major
elective surgery was cancelled whenever there was no guaranteed availability of
an ICU bed.
THE BURN UNIT
Just before Trunkey left for Oregon, he named Jan Horn director of the
Burn Unit. Horn had some experience with burns at Bellevue Hospital, where he
had trained. He immediately joined the American Burn Association and invested
a considerable amount of time in working closely with the committed cadre of
burn nurses.
Lewis did not take a strong position in favor of the Unit because of the
small number of burn patients. After Trunkey left, there was no one else in the
Department who had a great interest in burns. Other burn units were siphoning
off patients. Arguably, because of new sprinkler laws that cut the incidence of
fires in public buildings, there were a dwindling number of patients who
required hospital admission. Because of City economic problems, funding for
nurses was being reduced. The administrator of the hospital was in favor of
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closing the Unit because the care of burn patients was very expensive. Due to
lack of leadership, lack of strong interest, dwindling numbers of patients, and
expense, the decision was made to close the Unit. The Burn Unit closed over the
objections of the burn nurses who cherished it. The hospital continued to take
care of burns in the ICU, but it was not a very effective program.
THE NURSING SERVICE
The Nursing Service and the Department got along very well during
Lewis’s tenure. Lewis believed in and supported the Nursing profession. He was
always willing to logically and quietly discuss issues brought up by nurses. He
was “a great person to bounce ideas off and was highly respected by the Nursing
Service,” said a former Emergency Services Coordinator for the City and
County of San Francisco.
The nurses were very well paid as a result of their Union—the
Teamsters Union—which was strong and very good in bargaining negotiations.
There were no strikes or crises following the 1988 agreement on nurse staffing
ratios. “Deanna Mooney, one of the most intelligent nurses at the hospital, was
centrally involved in negotiations. Mooney also ran Central Processing and
Distribution—the source of all supplies and equipment, all purchases, and all
sterilization—and she managed it with extraordinary competence,” according to
Lewis.
TRAUMA REGULATIONS IN CALIFORNIA
The history of trauma regulations in California is fascinating, and
Lewis’s part in them is very important. It begins in the mid 1970s, before
regulations were even thought of—when Art Agnos, later the Mayor of San
Francisco and California State Assemblyman, was a social worker living on
Potrero Hill. In 1975, Agnos was shot by a group of men called the Zebra
killers by the news media because they were a group of blacks who victimized
only whites. He sustained major injuries to his stomach, pancreas, and colon and
was taken to SFGH, where he was operated on by Carol Raviola, the chief
surgical resident, and Donald Trunkey. Agnos survived and later returned to
have his colostomy closed. He and Trunkey became friendly, and, as a result of
his experience and Trunkey’s mentoring, Agnos became a strong supporter of
trauma centers.
A few years after Agnos was shot and cared for by Trunkey, Agnos
was elected to the legislature and, as trauma was a hot political issue at the time,
he wanted to sponsor a trauma bill and trauma regulations to establish a
statewide system for California. Trunkey and Lewis wrote a short bill at Agnos’
request that would establish a nucleus of activity to generate a trauma system.
Art Agnos introduced the bill into the legislature. Lewis and Trunkey had not
sufficiently recognized the political power of emergency room (ER) doctors who
opposed the bill because they were not a major part of the trauma system that
Lewis and Trunkey envisioned. One particular legislator, who was in the pocket
of American College of Emergency Physicians (ACEP), stonewalled the bill. It
sat for over a year, and nothing happened.
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Lewis realized the bill would never go anywhere if two groups of
doctors were fighting over it, so as chair of the Northern California Committee
on Trauma of the American College of Surgeons, Lewis called a meeting in San
Francisco. He had three chairs of the trauma committees in California attend for
the surgeons. He invited the past, present, and future presidents of ACEP to
represent the ER doctors. They met for a long day and hashed out their
differences, generating a bill that was acceptable to both sides. The revised bill
was sent back to Agnos and State Sen. Kenneth L. Maddy, and it was passed in
two weeks.
This bill resulted in establishment of the Emergency Medical Services
(EMS) Authority, which was the executive body in Sacramento, and an EMS
Commission, which was the oversight advisory body. Lewis was one of the
original appointees to the EMS Commission, and several months later—when
the commission appointed a subcommittee to actually draft the trauma
regulations—Lewis was appointed to co-chair that committee with an ER
physician from UCLA. The committee met several times over the year—with
most of the meetings held at Lewis’s house in Hillsborough—and the members
drafted complete regulations, sending them back to the EMS Commission for
ratification.
There was then a long period of public comment and multiple
Commission meetings devoted to dealing with details. In addition, even though
the community ER physicians were directly involved in drafting the regulations,
they took an opposing position because they felt trauma patients would bypass
local hospitals in favor of trauma centers, thereby reducing their business. There
were a series of increasingly contentious meetings of the EMS Commission.
Because the lay members constituted a majority on the Commission, the whole
question turned on which group of doctors could be more convincing to the lay
members when it came time for approval. The crucial meeting was held at the
San Francisco Airport. Lewis had arranged for Trunkey and two or three other
surgical representatives to come and speak to the Commission before the vote.
They provided the rationale for a strong advocacy of trauma centers and a
restrictive policy in their designation so the numbers would be controlled.
The ER opposition centered on Ron Crowell, who was also a
Commissioner, a past president of ACEP, and a politically powerful force, both
in ACEP and in the State. Crowell was politically adept and, at the time, he was
chair of the Commission and Lewis was vice chair. Lewis knew he would use
parliamentary rules to defeat the measure if he could.
On the crucial day, the meeting convened around 8 AM, and Lewis’s
litany of speakers provided their testimony from then until around 9:30 AM. For
some reason, Crowell did not show for the meeting! As vice chair, therefore,
Lewis ran the meeting. Seeing this as a golden opportunity, Lewis pushed things
forward as rapidly as possible and had the whole thing ready for a vote around
10 AM. Just at that time, Crowell burst in with great fanfare. It turned out his car
had been rear-ended on the way to the Los Angeles airport, and he had missed
his original flight. He was apprised of what had transpired and spoke eloquently
against it, but by then it was too late, as most of the lay members had made up
their minds. The vote went strongly for the rules advocated by the surgeons and
California got trauma regulations. To this day, Ron accuses Lewis of hiring the
guy who rear-ended him.
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TESTING PHYSICIANS FOR AIDS
In the 1980s, AIDS was a political “hot potato.” The Centers for
Disease Control and Prevention (CDC) concluded, in the late 1980s, that doctors
should be tested for HIV, and those who were positive should be prohibited
from contact with patients in any way that could transmit the disease—for
example, in surgery. This proposal was based in large part on the case of an
HIV-positive dentist and his patient who contracted HIV. It was never
unequivocally determined that the patient contracted the disease from the
dentist.
The American College of Surgeons became heavily involved in this
issue and Paul Ebert, who was executive director of the College at the time,
appointed Lewis to a relevant committee to draft the College’s policy on the
matter. At a national CDC meeting in Atlanta, Ebert and Lewis presented the
College’s position, which took sharp issue with the CDC proposal. According
to Lewis, the College was the only professional group that objected to the CDC
proposal. Lewis recalls that he reviewed the CDC numbers that were published
to justify its recommendation and concluded that they were mathematically
incorrect—their estimates of transmission of disease from doctors to their
patients were based on the incidence of transmission from patients to doctors
and were much too high for the operating room environment. Therefore, they
did not justify the CDC policy proposals with reasonable data. The College
pointed out that one of the consequences of the CDC policy would be to isolate
AIDS patients and deny them care because no one would risk contact with them
if their livelihood were at stake. Lewis says that he does not know whether their
testimony had much impact or not, but gradually the hysteria abated, and
fortunately the CDC never adopted its proposed policy.
RESIDENTS’ RECOLLECTIONS OF LEWIS
Spanky
Lewis’s nickname among the residents was “Spanky,” after the
character in Our Gang. It was given to him by anesthesiologist Dick Barber,
who was the only one who dared call him by the nickname to his face. When
the actor who played Spanky died and his adult photo was published with his
obituary, he could have easily been mistaken for Lewis.
Undue Influence
Lewis became almost livid one time when he realized that there was a
positive correlation between which drug company representative had most
recently visited the Surgery house staff with gifts of food and the residents’
selection of antibiotics.
Morbidity and Mortality Conference
When Lewis led M&M, the residents knew that they had to look
critically at their complications, be prepared to defend their actions, deal with
them, and own up to them.
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Unflappable and Fair Chief
“Lewis was unflappable in all circumstances, inside and outside the
operating room. He was a very fair, very even-handed chief of Surgery, and I
enjoyed serving with him during my time at San Francisco General.” (…as told
by Steve Raper)
The Lewis Doctrine
“A patient does not need two indications for a laparotomy.” This was
said in regard to unnecessary CT scans.
Gourmet Dinners
Lewis’s dinners at his home in
Hillsborough for seniors and chiefs had a
gourmet class reputation both for food
and wine. His consummate hostess, to
whom he is now married, was Janet
Christensen. As was true in the Trunkey
period, his staff enjoyed lively parties,
which were put on any time an occasion
might justify it. (…as told by Bill
Schecter)
Teaching in the Middle of the Night
Schecter, Knudson & Mackersie
“At approximately 2 AM, a young man
Party Time
came in with a gunshot wound to his left
arm completely severing his brachial artery. Lewis took me, a third-year
resident, patiently through a primary of the brachial artery, demonstrating the
triangulation technique, despite the fact that it was the middle of the night.”
(…as told by Tim Crombleholm)
Fluid Shifts Impress
Tranbaugh and Lewis presented Grand Rounds on lung water and the
role that extravascular fluid shifts played in pulmonary injury after severe
trauma. “This was quite exciting to me at the time, as it changed my views on
how trauma needed to be treated.” (…as told by Steve Raper)
Focusing a Resident’s Attention
On a senior resident’s first day on the Trauma Service, Lewis took him
aside and reviewed situations that were considered avoidable complications and
deaths during the previous five to six years. “I believe that this was a very
effective way of focusing a senior resident’s attention on the job. I could feel my
pulse quicken during this meeting in his office. In short, I think it tightened my
approach up considerably for the next two months on rotation.” (…as told by
Mike Longaker)
Teaching Effectiveness
“He taught me a lot, in my expectations of myself and my expectations
for my patients. He taught me to look hard for complications and deal with
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them. Under his leadership at SFGH, we saved a lot of lives. He really
influenced the way I think of things, surgical and otherwise. I think people
should know that.” (…as told by Steve Raper)
Expectations of His Residents
“As an intern, I was given a cholecystectomy to do, and Lewis was the
attending. We met in the xray department and went through the patient’s history
and findings, and we looked over the ultrasound exam. Dr. Lewis described the
different ways to diagnose cholecystitis and/or cholelithiasis. Then we went to
the patient, went through the history and exam again, and checked the laboratory
data. Next, we went over the consent and what to say. Then, before we parted he
said, ‘Tomorrow I don’t want any uncertainties regarding anatomy and
variations of such when I ask.’ I went home and studied. The case went great
and postoperatively we talked daily about the patient’s course and what to look
for. When the patient was discharged, we talked about follow-up and possible
future problems. As a professor in Sweden, I have applied much of this in my
teaching.” (…as told by Claes Skioldebrand)
Coolness under Fire
At that time, stab wounds were explored under local anesthesia in the
ER, and if found to penetrate the peritoneum, they were explored in the
operating room. In one case, the chief resident and Lewis were surprised to see a
large hematoma in the retroperitoneum, and, after they mobilized the right
colon, a briskly bleeding vena cava was found. Lewis was able to control the
bleeding with pressure while a side-biting clamp was applied and the wound
sutured. Then they proceeded to turn the cava over to rule out a wound of the
posterior wall. Lewis showed coolness and almost nonchalance as they
controlled what at the time seemed to be a devastating injury. (…Steve Raper)
Art of Fly-Fishing
The younger Lewis
showed considerable promise as
a beginning fly-fisherman. He
intuitively realized that there
was more than science in flyfishing, and therefore did not try
to reduce fly-fishing to a series
of
mathematical
formulae.
Rather, he relied on the
centuries-tested elements of
plenty of sleep and red wine.
Unfortunately, the increasing
demands of academic surgery
prevented his reaching his early
promise. His favorite fishing
companions were Joe Walsh and
Norman Christensen, shown
here. (…as told by Norm Christensen)
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INCIDENTS & ANECDOTES
The Temple of Doom
When Ward 5A was established in 1983, there was little that could be
done for AIDS patients, and most admitted to the ward died, sometimes
horribly. Surgical residents—being surgical residents—quickly began to call the
ward, “The Temple of Doom,” after the popular Indiana Jones film. While the
term was politically incorrect and deeply offended the nurses and medical staff
on the ward, the name stuck.
Leo Eloesser
A resident remembers admiring the portraits in the front lobby of
SFGH, and in particular the portrait of Dr. Leo Eloesser by Frida Kahlo, as well
as the painting The Tortilla by Diego Rivera. He recalls listening to Bill
Schecter talk of the life and history of Leo Eloesser, who is a legend not only at
SFGH but in Mexico as well. Eloesser lived and taught that the indigent or poor
should get the exact same level of care as the captains of industry. (…as told by
Stephen Raper)
Musings of a Chief Resident
The anxiety of running to answer the page, “Trauma room one, trauma
room one, STAT.” Lots of cases. Try to be a good team leader. Work under
pressure and when tired. Get to know all kinds of personnel working there
better.
Eats
Getting served a “midnight snack” by the “enormous guy in the “Café
General,” Barry. He knew the name of every resident, medical student, and
attending and was a friend to all. Getting served breakfast after a tough night by
the always smiling and friendly lady in the cafeteria.
“Mission Mary”
Mary O’Connor, who was head nurse in the ER and who had been
there a long time, could make a rookie resident nervous. “Blaisdell would not
have done this and Trunkey would have done that,” she would say. This was not
always what the chief resident wanted to hear in the middle of his or her first
tough ER trauma arrest. She was an outstanding clinical nurse and nursing
leader—tough as nails with a heart of gold. (…as told by Bill Schecter)
The “Roach Coach”
This truck parked outside the ER about 4 AM to serve sandwiches, chili
dogs, soda, coffee, and so forth, to hungry interns and residents as they strived to
get through the last call of the night and finish their scut work. The stuff on the
van truck was left over from previous stops and was in poor condition. Someone
at one time had seen roaches crawling around the merchandise—hence the name
Roach Coach.
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Catching Up on the Newspaper
Bill Schecter walking and reading the New York Times as he came into
the hospital in the morning.
Cause of a Sleep Disorder
A giant patient, headed for jail with a probable murder sentence,
swearing revenge because I had “stuck that tube in my thing” during ER
resuscitation. I had a sleeping disorder for some time after that.
Helluva Christmas
A visit by the Hell’s Angels one holiday season. A surreal scene,
watching big hairy bikers, a rough looking bunch, wearing Santa hats and
handing out presents to the children on the pediatric ward.
A Scene to Remember
The sense of the surrealistic while standing back and just observing the
male ward for a couple of moments in the middle of the night. There was
someone in four-point restraints having a seizure and, next to that patient, a
terminally ill, very old, quiet, thin Chinese man with a wart on his face from
which a long, single strand of hair grew. Next to him, a confused alcoholic
trying to untangle the Kerlix wrapped around the IV. In the other corner, a
medical student on the Extremity Service trying to take a history and physical on
his fifth patient since 9 PM. On the desk table, a half-drunk coffee cup and
remnants of a dry doughnut share space with a radio softly playing Cyndi
Lauper’s latest hit.
A Dramatic Case
A lifetime impression was made on a senior resident when a patient
came in with signs of tamponade and a single stab wound in the left anterior
chest over the pericardium. Bob Lim was the attending. The patient had no vital
signs and was rushed to the operating room, where his chest was rapidly prepped
and draped and preparations were made for a mediastinotomy to repair the
injury. The patient was given succinylcholine but essentially no anesthetic. I will
never forget, as I began making an incision over the sternum, the
anesthesiologist leaning over and saying to the still conscious patient: “You
won’t be able to move and you’ll feel a little pressure on your chest now.” We
opened the sternum and pericardium and found a single laceration in the right
ventricle. Dr. Lim was calm and collected. His main focus was to ask me not to
continue to hold the needle, once we placed the needle in the beating heart,
because of the risk of causing a greater laceration, but to make short quick
pushes of the needle through the ventricle. Several sutures stopped the bleeding
and the patient went home approximately 48 hours later. (…as told by Stephen
Raper)
Black Power
In l990, a representative of the State Fire Marshal’s office visited the
Department of Surgery offices. The Surgery offices were in a converted
patients’ ward, with secretarial cubicles extending into the ward hallway,
leaving the walk space narrowed down to 42 inches, the minimum necessary in a
public office but much too narrow for a patients’ ward. The State Marshal’s
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Office told the Department that it would have to rip out all of the cubicles and
restore the original eight-foot space between the walls to comply with code. The
hospital administration, the City Fire Marshal, and Mayor Art Agnos seemed
powerless to fix the problem.
Several months later, the State Marshal’s office again came around,
and—finding that nothing had changed—gave the Department until January 1st
to remove the cubicles or the Fire Marshal would send in a wrecking crew to
take them out. We re-emphasized that these were offices, not a patients’ ward,
but this carried no weight with the State Fire Marshal.
In desperation, Lewis called Willie Brown, who was still Speaker of the
California Assembly, and explained matters to him. Lewis had met Brown years
before, when he and Trunkey were dealing with the State Legislature over
trauma regulations. After the conversation with Brown, results were immediate.
Two days after the phone conversation, Lewis got a call, later followed by a
letter, from the State Fire Marshal himself. He apologized for the inconvenience
that Lewis and his staff had been put through. He further said that he had not
understood the details—that under the circumstances, the Department of Surgery
was clearly within regulations and need not change anything. Lewis says that, if
he were still in San Francisco, he would vote for Willie Brown for any office he
could name.
AIDS “No Risk”
Frank Lewis recalls sticking himself twice with a needle while doing an
open lung biopsy on an AIDS patient. He was assured by Julie Gerberding—
who was the SFGH guru on the subject, and who is now the director of the
Centers for Disease Control—that he had little to worry about, as it was still
thought that the disease was transmitted only by sexual contact.
Reducing Risk
Merle Sande, the chief of Medicine, who was in overall charge of the
AIDS program, considered Schecter one of the heroes of the AIDS epidemic.
Julie Gerberding and Bill Schecter worked together to allay the fears of surgeons
and develop ways of reducing risk. Schecter espoused the view that surgeons
had a responsibility to care for AIDS patients while he developed ways of
reducing risk, such as minimizing the use of sharp instruments and using trays to
pass instruments.
STAFF MEMBERS’ COMMENTS ON THE LEWIS YEARS
By 1992, it was apparent that Lewis was troubled by the weight of the
politics of his job. His relationships with the UCSF Department chair had
progressively soured, as he kept insisting that UC provide appropriate resources
for his SFGH program. The loss of University FTE’s (salaried positions) over
the years resulted in his service becoming practice driven at the expense of
academic accomplishment, and he feared for survival of his junior faculty. As
always, he mounted a well-reasoned attack on his lack of support and, because it
was so effective, it only compromised his relationships even more. When it was
finally apparent that he was up against a stone wall, he felt that his best option
was to look elsewhere for a new position. The opportunity presented itself when
211
Henry Ford Hospital, a major teaching hospital in Detroit allied with the
University of Michigan, offered him the position of chief of Surgery at a salary
level that was difficult to refuse.
He accepted the job offer, effective
September
1992.
Schecter
successfully negotiated additional
FTE support and funds to construct
a modern basic science laboratory
as part of his recruitment package
after Lewis’ departure. Lewis
married Janet Christensen, his
long-time friend and laboratory
technician shortly after moving to
Detroit. The wedding ceremony
was held in the San Francisco
home of Bob Mackersie, and many
Frank & Janet Newlyweds
of their friends were able to attend.
Lewis proved to be a remarkably effective leader at Henry Ford
Hospital, and moved from there to Philadelphia in 2002 to become the
Executive Director of the American Board of Surgery.
Bill Schecter recalls…
Frank had a unique ability to express complex physiologic relationships
in mathematical terms. He spent considerable time, including research time, in
either clarifying medical concepts, or debunking misconceptions. Examples are
his work with Robert Tranbaugh on the cause of pulmonary edema after trauma
and burns, and his work with Paul Hansen debunking the concept of
supranormal oxygen consumption.
Peggy Knudson recalls…
I arrived at San Francisco General Hospital in 1989, after having served
as the Trauma director at San Jose Medical Center for three years and spending
another three years as the associate director for Trauma at Stanford Medical
Center under John Collins. At both of my prior positions, my appointments were
clinical in nature, but Frank Lewis gave me the opportunity to try my hand in the
academic track. He had just been awarded a grant from the Centers for Disease
Control Injury Center, and he was willing to give me some limited funding from
the grant to start my “paper writing.” He also insisted that I learn to use a
computer (my first time!)—and after his prodding, I actually became quite
efficient on an old IBM computer that still had DOS programming. Frank was
quite opinionated about several things. For example, he hated MACs and loved
PCs. For my very first paper that was presented at a national meeting, he
changed all of my slides and insisted that I write out my talk—and thank God
for both! He taught me experimental design and how to critically evaluate
literature and experiments.
Although he was a master surgeon, and happiest when in the OR, he
also had strong opinions about clinical care. For example, one day on rounds, I
found that all of the retention sutures on a patient of mine had been removed by
212
Dr. Lewis! Believe me, I never used retention sutures again. Even after his
departure from SFGH, Frank continued to be a champion for my advancement
in academic trauma surgery, and I continue to be grateful for his support.
Bill Blaisdell recalls…
Frank Lewis was one of the brightest residents I ever trained. Actually,
he might rightly claim to have trained me, as he always had the answers to any
question and was quick to point out my errors and mistakes. His quick and
analytical mind was amazing to behold. When it came time to consider him for
staff, there was no question that I wanted him, but this involved financial risk
related to the soft money needed for his salary. As a result, I felt compelled to
present the decision to the five other members of our team. Everyone agreed that
he was outstanding—moreover, he would add the touch of a connoisseur to the
Department and immediately upgrade our social standing. The vote was
unanimous—we had to have him!
Norman Christensen recalls…
Frank Lewis has always reminded me of Richard Feynman by his
demeanor, his love of life, the way he looked at and solved problems, and how
he communicated with others. Although he was not a Nobel Laureate, as
Richard Feynman was—in Physics in 1965—both attended Princeton
University, and there were other striking similarities between the
two. …Remember Feynman? He showed a Congressional Committee
investigating the spacecraft Challenger disaster what caused the ‘O’ rings to fail
Frank Lewis Staff with Significant Others
213
by simply dousing them in water. Frank has the same ability to analyze
problems. They were both brilliant and analytical thinkers, disdained dogma,
and were always curious about how things worked—and each had the ability to
explain complex matters in understandable terms. Yet both were enjoyable and
entertaining companions, enjoying good food, wine, the other sex, and
challenging discussions. I do not know about Feynman, but Frank would
sometimes try to bring closure to a discussion (or argument) by proclaiming, “In
point of fact…,” sometimes uttering this with more intellectual vigor than
perhaps the situation required. Of course, Frank is human and has some
frailties—perhaps the worst was, and is, infatuation with fast cars. Fortunately
he lived through his attachment to an Aston Martin—an English racing car
with an extreme engine and no brakes—that he would drive from Hillsborough
to San Francisco General Hospital.
CHIEF RESIDENTS — THE FRANK LEWIS YEARS
1986-1987
Boyes, Stephen (Steve)
Kerley, Suzanne
Raper, Stephen (Steve)
Skioldebrand, Claes
Slate, Kenneth (Ken)
Weinstein, Joel
1987-1988
Duh, Quan-Yang
Flake, Alan
McVicar, John
Olive, Chapman
Sauer, Loie
Stevens, Michael (Mike)
1988-1989
Levin, Kenneth (Ken)
Nelken, Nic
Okuhn, Steve
Peper, Eric
Rabkin, John
Smith, Alison
1989-1990
Brunel, Wiley
Eshima, Issa
Gemlo, Brett
Paty, Phil
Schneider, Peter
Siperstein, Allan
1990-1991
Barker, Bruce
Ciresi, Kevin
Crombleholme, Tim
Fraker, Doug
Heck, Christopher
Lee, Roberta
Smedira, Nic
Whitney, Tim
1991-1992
Bland, Greg
Flynn, Art
Gray, John
Meyer, Rebecca
Moelleken, Brent
Orloff, George
Orloff, Susan
Rosas, Efren
1992-1993
Crochelt, Robert
Doherty, Gerald
Farmer, Diana
Harris, Hobart
Longaker, Michael
Salo, Jon
Wright, Fred
214
LEWIS’S RESEARCH FELLOWS DURING HIS CAREER AT SFGH
(1978-1992)
Lewis’s fellows’ research focused on extravascular lung
water, capillary permeability ranges, neurogenic pulmonary edema,
crystalloid resuscitation versus colloid fluid resuscitation, and oxygen
consumption and adrenergic agents.
1977-1978
Johannes Sturm, M.D.
l978
Luis Oppenheimer, M.D.
l978-1979
Steven Hill, M.D.
l979-1981
Robert Tranbaugh, M.D.
l981-83
Robert Mackersie, M.D.
l982-1984
Fred Bongard, M.D.
l983-1984
Louis Ostrow, M.D.
l984-1985
Arun Gosain, M.D.
l985-1987
Nic Nelken, M.D.
l987-1989
Bruce Barker, M.D.
l987-1989
Johannes Bock, M.D.
l990-1992
Paul Hansen, M.D.
Johannes Sturm is a professor of Surgery in Germany. He was
awarded the Residents' Research Award from the Association for Academic
Surgery in l978. Lewis considers him to be his “most rewarding fellow,” as he
went from “virtually no awareness of research to tremendous expertise in
designing and carrying out experiments. He developed a zeal for research and an
understanding of physiology that was probably greater than any of the others’.”
On his return to Germany, Sturm greatly influenced trauma research and was
pivotal in securing research funding by the German equivalent of the NIH for a
major multicenter study of trauma. Lewis says that, on his return to Germany,
Sturm was the only surgeon talking knowledgeably about critical care, as until
then critical care had been the purview of the anesthesiologists.
Luis Oppenheimer returned to the University of Winnipeg, where he
is now a professor of Surgery. There, he worked productively in critical care and
continued his research on pulmonary failure.
Steven Hill is in private practice, doing almost exclusively vascular
surgery in Roanoke, Virginia. While a fellow, he sustained a gamekeeper's
thumb injury while skiing and, while a chief resident, he suffered a fractured
femur and other major injuries in a head-on crash when driving home one night.
He recovered without sequelae from these injuries.
Robert Tranbaugh is chief of the Division of Cardiac Surgery at Beth
Israel Medical Center in New York. Lewis considers him to be the best of all his
215
fellows. At the end of two years of fellowship, he had published 23 papers. His
awards included: American College of Surgeons (ACS) Committee on Trauma
National Residents’ Award in 1981; American Trauma Society Young
Investigators’ Award in 1981; and American College of Chest Physicians best
research paper in 1981. He gave very polished presentations and won more
research rewards than any of Lewis's other fellows. One of his most interesting
papers was delivered to the American Surgical Association in 1980, in which he
and Lewis showed that the primary determinant of pulmonary edema after burns
was the onset of sepsis, and that massive crystalloid resuscitation did not result
in increased extra-vascular lung water. The paper was harshly criticized by Dr.
Francis Moore of Harvard.
Robert Mackersie is now at SFGH, where he is professor of Surgery
and chief of the Trauma Service.
Fred Bongard is professor of Surgery at Harbor-UCLA Medical
Center.
Louis Ostrow, an Air Force career medical officer, was very
productive. His awards included: The Resident’s Research Award, Region IX,
ACS Committee on Trauma; the l984 Resident’s Research Award, Military
Region; and the ACS Committee on Trauma Award in l985.
Arun Gosain completed his training in General Surgery in New Jersey
and subsequently trained in Plastic and Reconstructive Surgery at the University
of Wisconsin, where he joined the faculty. He went on to a distinguished career
in academic Plastic and Reconstructive Surgery as a craniofacial surgeon.
Nic Nelken is in the practice of vascular surgery in Honolulu, Hawaii.
Bruce Barker went into practice in San Francisco at the Kaiser
Foundation Hospital.
Johannes Bock returned to Germany, where he completed a Radiology
residency. Lewis comments that Bock was extraordinarily smart, with an
excellent mathematical background—and when last heard from, he was doing
some leading edge work in computerized imaging.
Paul Hansen is in private practice at the Oregon Clinic in Portland,
where he remains active in research and is director of Surgical Education.